Provider Demographics
NPI:1710479399
Name:KOZLOWSKI, CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:
Last Name:KOZLOWSKI
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 1:1277 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-4605
Mailing Address - Country:US
Mailing Address - Phone:231-672-6186
Mailing Address - Fax:231-672-6181
Practice Address - Street 1:1277 MERCY DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-4605
Practice Address - Country:US
Practice Address - Phone:231-672-6186
Practice Address - Fax:231-672-6181
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27-1511893207R00000X
MI4301504087207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicaid