1629022280 NPI number — WILLIAM G KODZAI MD

Table of content: WILLIAM G KODZAI MD (NPI 1629022280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629022280 NPI number — WILLIAM G KODZAI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KODZAI
Provider First Name:
WILLIAM
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629022280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 E MOREHEAD ST
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28202-2788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-334-7800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 E MOREHEAD ST
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28202-2788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-334-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2006

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: 2085R0202X , with the licence number:  230005-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 40305 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 200400533 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: N0053A , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00336785 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89137FC , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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