Basic Information
| Provider Information | |||||||||
| NPI: | 1609833409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOZAK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52817 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850722817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807635808 | ||||||||
| FaxNumber: | 4807590647 | ||||||||
| Practice Location | |||||||||
| Address1: | 4530 EAST MUIRWOOD DRIVE | ||||||||
| Address2: | STE 110 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807635808 | ||||||||
| FaxNumber: | 4807590647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 01/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 23442 | AZ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 319279 | 05 | AZ | MEDICAID |