Healthcare Provider Details

I. General information

NPI: 1093111551
Provider Name (Legal Business Name): JOHN KOZLIK II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 E BROAD ST BLDG 11, SECTION 11
COLUMBUS OH
43213-1152
US

IV. Provider business mailing address

3990 E BROAD ST BLDG 11, SECTION 11
COLUMBUS OH
43213-1152
US

V. Phone/Fax

Practice location:
  • Phone: 614-336-7376
  • Fax:
Mailing address:
  • Phone: 614-336-7376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: