Healthcare Provider Details

I. General information

NPI: 1598148033
Provider Name (Legal Business Name): YULYA KOZLOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 N PEARL ST
BROCKTON MA
02301-1794
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 508-427-3000
  • Fax:
Mailing address:
  • Phone: 617-947-1312
  • Fax: 617-789-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number278789
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: