Provider Demographics
NPI:1598740631
Name:KOZLOWSKI, JEFFREY DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:KOZLOWSKI
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:PO BOX 110566
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27709-5566
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:336 GEORGIA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3849
Practice Address - Country:US
Practice Address - Phone:803-442-3006
Practice Address - Fax:803-642-0754
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1102152W00000X
NC1734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDN1734Medicaid
SCAA73227125OtherMEDICARE PTAN
SCAA73227125OtherMEDICARE PTAN