Provider Demographics
NPI:1891058228
Name:KOZICKY, MARK WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WALTER
Last Name:KOZICKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:967 N BROADWAY
Mailing Address - Street 2:ST. JOHNS RIVERSIDE HOSPITAL OFFICE OF GRADUATE MED ED
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701
Mailing Address - Country:US
Mailing Address - Phone:914-964-4444
Mailing Address - Fax:
Practice Address - Street 1:967 N BROADWAY
Practice Address - Street 2:ST. JOHNS RIVERSIDE HOSPITAL
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701
Practice Address - Country:US
Practice Address - Phone:914-964-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine