Provider Demographics
NPI:1821074014
Name:KOZAM, MARC LYLE (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:LYLE
Last Name:KOZAM
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Gender:M
Credentials:MD
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Mailing Address - Street 1:18111 PRINCE PHILIP DR
Mailing Address - Street 2:SUITE T-14
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1513
Mailing Address - Country:US
Mailing Address - Phone:301-774-4400
Mailing Address - Fax:301-774-1034
Practice Address - Street 1:18111 PRINCE PHILIP DR
Practice Address - Street 2:SUITE T-14
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1513
Practice Address - Country:US
Practice Address - Phone:301-774-4400
Practice Address - Fax:301-774-1034
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2013-09-17
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Provider Licenses
StateLicense IDTaxonomies
MDD44289207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD090907600Medicaid
MD090907600Medicaid
G26481Medicare UPIN