Provider Demographics
NPI:1689255028
Name:KOZAK, MARY ELIZABETH COPELAND (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH COPELAND
Last Name:KOZAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:COPELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:815 MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1080
Mailing Address - Country:US
Mailing Address - Phone:309-672-4977
Mailing Address - Fax:
Practice Address - Street 1:815 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1080
Practice Address - Country:US
Practice Address - Phone:309-672-4977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program