Provider Demographics
NPI:1780129825
Name:KOCZWARA, KONRAD RICHARD (PT)
Entity type:Individual
Prefix:
First Name:KONRAD
Middle Name:RICHARD
Last Name:KOCZWARA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8036 W BERWYN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-1502
Mailing Address - Country:US
Mailing Address - Phone:773-510-4312
Mailing Address - Fax:
Practice Address - Street 1:1115 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4103
Practice Address - Country:US
Practice Address - Phone:773-510-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.022449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist