Provider Demographics
NPI:1568460525
Name:KOZAWA, KENYA (MD)
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:
Last Name:KOZAWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1181
Mailing Address - Country:US
Mailing Address - Phone:865-213-8590
Mailing Address - Fax:865-213-8596
Practice Address - Street 1:304 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-1181
Practice Address - Country:US
Practice Address - Phone:865-213-8590
Practice Address - Fax:865-213-8596
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25483207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4121557OtherBLUE CROSS
TN3083016Medicaid
3083016Medicare ID - Type Unspecified
F11636Medicare UPIN