Provider Demographics
NPI:1407305097
Name:KOZLOSKI, JUSTIN PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:PAUL
Last Name:KOZLOSKI
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 1:82227 US HIGHWAY 111 STE B2
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5668
Mailing Address - Country:US
Mailing Address - Phone:760-347-6636
Mailing Address - Fax:
Practice Address - Street 1:82227 US HIGHWAY 111 STE B2
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5668
Practice Address - Country:US
Practice Address - Phone:760-347-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-24
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9078T152W00000X, 152WL0500X
CA33661152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation