Provider Demographics
NPI:1942317458
Name:KOSSOVER, STUART ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:ALLAN
Last Name:KOSSOVER
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:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-4195
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:2311 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8905
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36753207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
191498OtherMEDCOST
4339028OtherAETNA
562120765OtherUNITED HEALTHCARE
P00407181OtherRAILROAD MEDICARE
4113OtherPARTNERS
50201OtherBCBS
0489412OtherCIGNA
NC8950201Medicaid
NC8950201Medicaid
F55729Medicare UPIN