Provider Demographics
NPI:1316100126
Name:KOZAK, REBECCA (OD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:KOZAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:EISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:160 N GULPH RD
Mailing Address - Street 2:LENS CRAFTERS
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406
Mailing Address - Country:US
Mailing Address - Phone:610-962-5945
Mailing Address - Fax:610-962-5948
Practice Address - Street 1:160 N GULPH RD
Practice Address - Street 2:LENS CRAFTERS
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406
Practice Address - Country:US
Practice Address - Phone:610-962-5945
Practice Address - Fax:610-962-5948
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002061152W00000X
RIODTG00542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1316100126Medicaid