Healthcare Provider Details

I. General information

NPI: 1194988980
Provider Name (Legal Business Name): JACOB JOHN KOCZMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14256 N NORTHSIGHT BLVD STE 120
SCOTTSDALE AZ
85260-3954
US

IV. Provider business mailing address

14256 N NORTHSIGHT BLVD STE 120
SCOTTSDALE AZ
85260-3954
US

V. Phone/Fax

Practice location:
  • Phone: 623-249-7589
  • Fax:
Mailing address:
  • Phone: 623-249-7589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11014550A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number274908
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberDR.0056977
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number11014550A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number66739
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: