Provider Demographics
NPI:1366548174
Name:KOSOBUCKI, BRIAN R (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:KOSOBUCKI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3333 BROOKVIEW HILLS BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5661
Mailing Address - Country:US
Mailing Address - Phone:336-970-5900
Mailing Address - Fax:336-842-3964
Practice Address - Street 1:3333 BROOKVIEW HILLS BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5661
Practice Address - Country:US
Practice Address - Phone:336-842-3780
Practice Address - Fax:336-842-3964
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200401088207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC804621OtherPARTNERS
NC1689048423Medicaid
NC137HTOtherBCBS
NCR000F360OtherMEDICARE PTAN
NC1689048423Medicaid