1205006277 NPI number — DR. GREGORY NICHOLAS KOZLOV DO

Table of content: DR. GREGORY NICHOLAS KOZLOV DO (NPI 1205006277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205006277 NPI number — DR. GREGORY NICHOLAS KOZLOV DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOZLOV
Provider First Name:
GREGORY
Provider Middle Name:
NICHOLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205006277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 37TH AVE N
Provider Second Line Business Mailing Address:
SUITE 125
Provider Business Mailing Address City Name:
SAINT PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33704-1416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 37TH AVE N
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
SAINT PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33704-1416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-331-2457
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  036.127771 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: 036.127771 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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