Provider Demographics
NPI:1083707533
Name:KODZ, THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KODZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6099
Mailing Address - Country:US
Mailing Address - Phone:203-739-7447
Mailing Address - Fax:203-749-9003
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-7447
Practice Address - Fax:203-749-9003
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ30536Medicare UPIN
CT970001705Medicare ID - Type Unspecified