Provider Demographics
NPI:1578684155
Name:KOZIOL, THEODORE M (DC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:M
Last Name:KOZIOL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 BRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6010
Mailing Address - Country:US
Mailing Address - Phone:732-477-6767
Mailing Address - Fax:732-477-9333
Practice Address - Street 1:387 BRICK BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6010
Practice Address - Country:US
Practice Address - Phone:732-477-6767
Practice Address - Fax:732-477-9333
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00329800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ536569Medicare ID - Type Unspecified
NJT45735Medicare UPIN