Provider Demographics
NPI:1124330410
Name:KOZICKI, MATTHEW NICHOLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:NICHOLAS
Last Name:KOZICKI
Suffix:
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:BLAKESLEE
Mailing Address - State:PA
Mailing Address - Zip Code:18610-0040
Mailing Address - Country:US
Mailing Address - Phone:570-646-8745
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 940 AND 115
Practice Address - Street 2:
Practice Address - City:BLAKESLEE
Practice Address - State:PA
Practice Address - Zip Code:18610
Practice Address - Country:US
Practice Address - Phone:570-646-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine