Provider Demographics
NPI:1124219241
Name:KOZAK, KEVIN R (MD, PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:KOZAK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 BOY SCOUT DR STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-2119
Mailing Address - Country:US
Mailing Address - Phone:239-215-1180
Mailing Address - Fax:239-215-1179
Practice Address - Street 1:25243 ELEMENTARY WAY
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7898
Practice Address - Country:US
Practice Address - Phone:239-317-2772
Practice Address - Fax:239-676-7637
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1483572085R0001X
WI516152085R0001X
IL0361211142085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIKOZAKKEVOtherMERCYCARE INSURANCE
FLHVZ5ROtherFL BLUE
FLNO241OtherMEDICARE
FL109765700Medicaid
IL$$$$$$$$$ 3Medicaid