Provider Demographics
NPI:1851322275
Name:KOZLOV, ILYA YUREVICH (MD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:YUREVICH
Last Name:KOZLOV
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 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:5TH FL ADMIN - DEPT OF OBGYN
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7606
Mailing Address - Country:US
Mailing Address - Phone:718-239-8383
Mailing Address - Fax:718-239-8360
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-239-8383
Practice Address - Fax:718-239-8360
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230644207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
9L2521Medicare ID - Type Unspecified
I20029Medicare UPIN