Healthcare Provider Details

I. General information

NPI: 1861482788
Provider Name (Legal Business Name): MARK EDWARD KOZMINSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2005
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 KENDRA ST
CHARLOTTESVILLE VA
22903-7955
US

IV. Provider business mailing address

1618 KENDRA ST
CHARLOTTESVILLE VA
22903-7955
US

V. Phone/Fax

Practice location:
  • Phone: 814-574-5131
  • Fax:
Mailing address:
  • Phone: 814-574-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD033463E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: