Provider Demographics
NPI:1417103961
Name:KOSZEWNIK, LATASHA WALTERS (DPM)
Entity type:Individual
Prefix:DR
First Name:LATASHA
Middle Name:WALTERS
Last Name:KOSZEWNIK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ENCINO DR.
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037
Mailing Address - Country:US
Mailing Address - Phone:619-920-8425
Mailing Address - Fax:
Practice Address - Street 1:610 ENCINO DR
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-5704
Practice Address - Country:US
Practice Address - Phone:619-920-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002304213E00000X
CAE5003213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist