Healthcare Provider Details

I. General information

NPI: 1487692661
Provider Name (Legal Business Name): LISA L KOZEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 9TH ST
BISMARCK ND
58501-4507
US

IV. Provider business mailing address

401 N 9TH ST
BISMARCK ND
58501-4507
US

V. Phone/Fax

Practice location:
  • Phone: 701-712-4500
  • Fax: 701-712-4098
Mailing address:
  • Phone: 701-712-4500
  • Fax: 701-712-4098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7620
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier10640
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: