MEDICARE: KOZLOW EYE CENTER PLLC

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	207W00000X	Ophthalmology Physician	4301054436	MI

General Provider Information

NPI Number	:	1891166575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOZLOW EYE CENTER PLLC

Provider Business Mailing Address
First Line	:	23874 KEAN STREET
Second Line	:	#130
City	:	DEARBORN
State	:	MI
Zip	:	48124-1804
Country	:	US
Telephone Number	:	313-626-0909
Fax Number	:	313-551-5688

Provider Business Practice Location Address
First Line	:	23874 KEAN ST
Second Line	:	#130
City	:	DEARBORN
State	:	MI
Zip	:	48124-1804
Country	:	US
Telephone Number	:	313-626-0909
Fax Number	:	313-551-5688

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DANIEL B KOZLOW
Credential	:	MD
Telephone Number	:	313-626-0909

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	01/31/2017

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