Healthcare Provider Details

I. General information

NPI: 1487015384
Provider Name (Legal Business Name): BENJAMIN MICHAEL KOZAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2016
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

2825 OAK LAWN AVE UNIT 192749
DALLAS TX
75219-4688
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-3726
  • Fax:
Mailing address:
  • Phone: 510-683-9500
  • Fax: 877-880-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2025-01005
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number55581
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number277329
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberT2656
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0091889
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.146016
License Number StateOH
# 7
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA202269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: