Healthcare Provider Details

I. General information

NPI: 1598740631
Provider Name (Legal Business Name): JEFFREY DAVID KOZLOWSKI OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 GEORGIA AVE SUITE 102
NORTH AUGUSTA SC
29841-3849
US

IV. Provider business mailing address

PO BOX 110566
DURHAM NC
27709-5566
US

V. Phone/Fax

Practice location:
  • Phone: 803-442-3006
  • Fax: 803-642-0754
Mailing address:
  • Phone: 919-620-4855
  • Fax: 919-620-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1102
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1734
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: