Provider Demographics
NPI:1609339753
Name:COZBY, JEREMIAH MATHEW I
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:MATHEW
Last Name:COZBY
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27440 POTTS MTN RD
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-3698
Mailing Address - Country:US
Mailing Address - Phone:918-413-2678
Mailing Address - Fax:
Practice Address - Street 1:27440 POTTS MTN RD
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-3698
Practice Address - Country:US
Practice Address - Phone:918-413-2678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKGAAA-NYOA-BIMU173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine