Provider Demographics
NPI:1861421620
Name:COSLOW, CARL RICHARD
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:RICHARD
Last Name:COSLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4656 W JEFFERSON BLVD
Mailing Address - Street 2:STE 285
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-422-9372
Mailing Address - Fax:260-422-0843
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:STE 285
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-422-9372
Practice Address - Fax:260-422-0843
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000209A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000143216OtherANTHEM
IN200806690AMedicaid
IN075209000OtherMAGELLAN
IN4405313OtherAETNA
IN280482OtherVALUE OPTIONS
IN075209000OtherMAGELLAN