Provider Demographics
NPI:1750597654
Name:KOZIC, HEIDI (MD)
Entity type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:
Last Name:KOZIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST
Mailing Address - Street 2:SUITE 740
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4414
Mailing Address - Country:US
Mailing Address - Phone:215-955-6680
Mailing Address - Fax:215-503-2556
Practice Address - Street 1:833 CHESTNUT ST
Practice Address - Street 2:SUITE 740
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:215-955-6680
Practice Address - Fax:215-503-2556
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008613207N00000X
PAMT181819207N00000X
PAMD432113207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102055628Medicaid
NJ0351610Medicaid
PA119498Medicare PIN