Provider Demographics
NPI:1285785527
Name:KOSANOVICH, TAD ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:TAD
Middle Name:ROBERT
Last Name:KOSANOVICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-3307
Mailing Address - Country:US
Mailing Address - Phone:941-473-1392
Mailing Address - Fax:941-473-9379
Practice Address - Street 1:150 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-3307
Practice Address - Country:US
Practice Address - Phone:941-473-1392
Practice Address - Fax:941-473-9379
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL410046559OtherRAILROAD MEDICARE
FL620138500Medicaid
FL410046559OtherRAILROAD MEDICARE
FLT90351Medicare UPIN