Basic Information
| Provider Information | |||||||||
| NPI: | 1891890638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | KOZHIMALA | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1839 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273221054 | ||||||||
| FaxNumber: | 7278217213 | ||||||||
| Practice Location | |||||||||
| Address1: | 6336 FORT KING RD | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273221054 | ||||||||
| FaxNumber: | 7278217213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME23148 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | ME23148 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 058391000 | 05 | FL | MEDICAID | 51086 | 01 | BCBS | OTHER |