Provider Demographics
NPI:1194988980
Name:KOCZMAN, JACOB JOHN (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:KOCZMAN
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 1:14256 N NORTHSIGHT BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3954
Mailing Address - Country:US
Mailing Address - Phone:623-249-7589
Mailing Address - Fax:
Practice Address - Street 1:14256 N NORTHSIGHT BLVD STE 120
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3954
Practice Address - Country:US
Practice Address - Phone:623-249-7589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014550A207R00000X, 207W00000X
NY274908207W00000X
CODR.0056977207W00000X
AZ66739207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25175114Medicaid