Provider Demographics
NPI:1750443073
Name:KOZLOV, KRISTI LYN (LLC)
Entity Type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:LYN
Last Name:KOZLOV
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SPRING HILL RING RD
Mailing Address - Street 2:STE 2020
Mailing Address - City:WEST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1297
Mailing Address - Country:US
Mailing Address - Phone:312-771-2007
Mailing Address - Fax:
Practice Address - Street 1:3100 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1603
Practice Address - Country:US
Practice Address - Phone:630-527-1920
Practice Address - Fax:630-527-0125
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103302207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02233058OtherBLUE CROSS BLUE SHIELD
ILG96971Medicare UPIN