Healthcare Provider Details

I. General information

NPI: 1750597654
Provider Name (Legal Business Name): HEIDI KOZIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 CHESTNUT ST SUITE 740
PHILADELPHIA PA
19107-4414
US

IV. Provider business mailing address

833 CHESTNUT ST SUITE 740
PHILADELPHIA PA
19107-4414
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6680
  • Fax: 215-503-2556
Mailing address:
  • Phone: 215-955-6680
  • Fax: 215-503-2556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC1-0008613
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMT181819
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD432113
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: