Healthcare Provider Details

I. General information

NPI: 1124330410
Provider Name (Legal Business Name): MATTHEW NICHOLAS KOZICKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 940 AND 115
BLAKESLEE PA
18610
US

IV. Provider business mailing address

PO BOX 40
BLAKESLEE PA
18610-0040
US

V. Phone/Fax

Practice location:
  • Phone: 570-646-8745
  • Fax:
Mailing address:
  • Phone: 570-646-8745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD449228
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: