Provider Demographics
NPI:1992852933
Name:KOZACHUK, WALTER ERNEST (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:ERNEST
Last Name:KOZACHUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11403 CAM CT
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-1313
Mailing Address - Country:US
Mailing Address - Phone:301-807-9346
Mailing Address - Fax:301-962-8815
Practice Address - Street 1:2328 W JOPPA RD
Practice Address - Street 2:SUITE 10
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4612
Practice Address - Country:US
Practice Address - Phone:410-828-7792
Practice Address - Fax:410-828-5620
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD37279207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF19312Medicare UPIN
MD722RMedicare ID - Type Unspecified