Provider Demographics
NPI:1912908914
Name:KOZAK, WILLIAM J JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:KOZAK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 ATHENA DR
Mailing Address - Street 2:
Mailing Address - City:DELMONT
Mailing Address - State:PA
Mailing Address - Zip Code:15626-1005
Mailing Address - Country:US
Mailing Address - Phone:724-468-6869
Mailing Address - Fax:724-468-6207
Practice Address - Street 1:2620 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-1488
Practice Address - Country:US
Practice Address - Phone:724-626-0700
Practice Address - Fax:724-626-8700
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019646830002Medicaid
PA0019646830002Medicaid
PAP00292333Medicare PIN
PA072097Medicare ID - Type Unspecified