Healthcare Provider Details

I. General information

NPI: 1366455644
Provider Name (Legal Business Name): MICHAEL KOZNARSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 REID ST ATTN MCHJ-QCR
TACOMA WA
98431-1100
US

IV. Provider business mailing address

65 JACKSON ST
STEILACOOM WA
98388-1721
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax:
Mailing address:
  • Phone: 253-983-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01058557A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: