Provider Demographics
NPI:1700829140
Name:KOZAKOWSKI, MARK HENRY (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:HENRY
Last Name:KOZAKOWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 SEQUALISH ST
Mailing Address - Street 2:
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-2522
Mailing Address - Country:US
Mailing Address - Phone:253-593-0232
Mailing Address - Fax:253-382-2091
Practice Address - Street 1:2209 E 32ND ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-4922
Practice Address - Country:US
Practice Address - Phone:253-593-0232
Practice Address - Fax:253-382-2091
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001192207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAKO5413OtherREGENCE
WA8144362Medicaid
WA40009OtherLABOR & INDUSTRIES
WAAB12914Medicare ID - Type Unspecified
WAKO5413OtherREGENCE