Healthcare Provider Details

I. General information

NPI: 1114974664
Provider Name (Legal Business Name): TOMASZ KOZLOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N CLYDE MORRIS BLVD STE 360
DAYTONA BEACH FL
32114-2757
US

IV. Provider business mailing address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-4650
  • Fax: 386-425-7510
Mailing address:
  • Phone: 386-425-0141
  • Fax: 386-226-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME139131
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberME139131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: