Healthcare Provider Details

I. General information

NPI: 1609098607
Provider Name (Legal Business Name): MARTHA SOCORRO KOZUB APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5514 HOHMAN AVE.
HAMMOND IN
46320
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-933-2018
  • Fax: 219-933-2647
Mailing address:
  • Phone: 317-528-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71000129A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: