=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295839942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEIGH C KOZAK O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 08/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 CHAPEL ST MEDICAL EYE CARE ASSOCIATES
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02062-3155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-333-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 CHAPEL ST MEDICAL EYE CARE ASSOCIATES
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02062-3155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3916
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------