Healthcare Provider Details

I. General information

NPI: 1821074014
Provider Name (Legal Business Name): MARC LYLE KOZAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18111 PRINCE PHILIP DR SUITE T-14
OLNEY MD
20832-1513
US

IV. Provider business mailing address

18111 PRINCE PHILIP DR SUITE T-14
OLNEY MD
20832-1513
US

V. Phone/Fax

Practice location:
  • Phone: 301-774-4400
  • Fax: 301-774-1034
Mailing address:
  • Phone: 301-774-4400
  • Fax: 301-774-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD44289
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: