Provider Demographics
NPI:1528814563
Name:KOSKOSKI, DEJAN (DPT)
Entity type:Individual
Prefix:
First Name:DEJAN
Middle Name:
Last Name:KOSKOSKI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:454 PASSAIC ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1519
Practice Address - Country:US
Practice Address - Phone:201-488-7905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02255300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist