=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487015384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN MICHAEL KOZAK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2016
-----------------------------------------------------
Last Update Date | 07/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 FRUIT ST
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02114-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-643-3726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2825 OAK LAWN AVE UNIT 192749
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-4688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-683-9500
-----------------------------------------------------
Fax | 877-880-2039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 2025-01005
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 55581
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 277329
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | T2656
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | D0091889
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 35.146016
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | A202269
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------