MEDICARE: DR. JEFFREY DAVID KOZLOWSKI OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1102	SC
2	152W00000X	Optometrist	1734	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	AA73227125	OTHER	SC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598740631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY DAVID KOZLOWSKI OD

Provider Business Mailing Address
First Line	:	PO BOX 110566
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27709-5566
Country	:	US
Telephone Number	:	919-620-4855
Fax Number	:	919-620-4921

Provider Business Practice Location Address
First Line	:	336 GEORGIA AVE
Second Line	:	SUITE 102
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-3849
Country	:	US
Telephone Number	:	803-442-3006
Fax Number	:	803-642-0754

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	05/04/2022

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