Healthcare Provider Details

I. General information

NPI: 1912918467
Provider Name (Legal Business Name): RICHARD KOZOLL, MD, LOS PINOS FAMILY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/22/2020
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 1659
CUBA NM
87013-1659
US

V. Phone/Fax

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

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: DR. RICHARD KOZOLL
Title or Position: PROPRIETOR
Credential: M.D.
Phone: 505-289-3326