Provider Demographics
NPI:1043655525
Name:KOSLOV, DAVID STEWART (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:STEWART
Last Name:KOSLOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4816
Mailing Address - Country:US
Mailing Address - Phone:909-882-2973
Mailing Address - Fax:909-882-2681
Practice Address - Street 1:489 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4816
Practice Address - Country:US
Practice Address - Phone:909-882-2973
Practice Address - Fax:909-882-2681
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0060248208800000X
CAA168921208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology