Provider Demographics
NPI:1619975992
Name:KOZICKY, PETER W (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:W
Last Name:KOZICKY
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:PO BOX 1347
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0347
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:50 MOISEY DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-9297
Practice Address - Country:US
Practice Address - Phone:570-501-6730
Practice Address - Fax:570-501-3837
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020512E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006446160003Medicaid
030720LPBMedicare PIN
B33682Medicare UPIN