Provider Demographics
NPI:1073687356
Name:COCOZIELLO, SUSAN PAKRAVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:PAKRAVAN
Last Name:COCOZIELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROADWAY
Mailing Address - Street 2:STE 105
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1843
Mailing Address - Country:UM
Mailing Address - Phone:201-794-7717
Mailing Address - Fax:201-794-7717
Practice Address - Street 1:1 BROADWAY
Practice Address - Street 2:SUITE 105
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1842
Practice Address - Country:US
Practice Address - Phone:201-773-6777
Practice Address - Fax:201-300-6880
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1915908Medicaid
NJE87105Medicare UPIN
NJ1915908Medicaid