Provider Demographics
NPI:1881242592
Name:COZZETTA, DOMENIC (OD)
Entity type:Individual
Prefix:MR
First Name:DOMENIC
Middle Name:
Last Name:COZZETTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1856
Mailing Address - Country:US
Mailing Address - Phone:719-542-3555
Mailing Address - Fax:
Practice Address - Street 1:1620 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1856
Practice Address - Country:US
Practice Address - Phone:719-542-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist