Healthcare Provider Details

I. General information

NPI: 1558302760
Provider Name (Legal Business Name): RICHARD LANDE KOZOLL M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6362 MAIN STREET
CUBA NM
87013
US

IV. Provider business mailing address

PO BOX 638
CUBA NM
87013-0638
US

V. Phone/Fax

Practice location:
  • Phone: 505-289-3326
  • Fax: 505-289-3390
Mailing address:
  • Phone: 505-289-3291
  • Fax: 505-289-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number72-173
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: