Provider Demographics
NPI:1043277973
Name:COZZETTA, MICHAEL R (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:COZZETTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1856
Mailing Address - Country:US
Mailing Address - Phone:719-542-3555
Mailing Address - Fax:719-542-0776
Practice Address - Street 1:1620 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1856
Practice Address - Country:US
Practice Address - Phone:719-542-3555
Practice Address - Fax:719-542-0776
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1347152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376983924OtherGROUP NPI
410014546OtherRAILROAD MEDICARE
1679744841OtherOFFICE NPI
CO8013476Medicaid
1679525208OtherGROUP OFFICE NPI
COC41603Medicare PIN
1376983924OtherGROUP NPI
COU18707Medicare UPIN