Healthcare Provider Details

I. General information

NPI: 1851322275
Provider Name (Legal Business Name): ILYA YUREVICH KOZLOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7606
US

IV. Provider business mailing address

1650 GRAND CONCOURSE 5TH FL ADMIN - DEPT OF OBGYN
BRONX NY
10457-7606
US

V. Phone/Fax

Practice location:
  • Phone: 718-239-8383
  • Fax: 718-239-8360
Mailing address:
  • Phone: 718-239-8383
  • Fax: 718-239-8360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number230644
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: