Provider Demographics
NPI:1316169766
Name:COZAN, THEODORA BETSY (OD)
Entity type:Individual
Prefix:
First Name:THEODORA
Middle Name:BETSY
Last Name:COZAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 SAYBROOK LANE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19086
Mailing Address - Country:US
Mailing Address - Phone:610-876-9416
Mailing Address - Fax:
Practice Address - Street 1:442 WEST LINCOLN HIGHWAY
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341
Practice Address - Country:US
Practice Address - Phone:610-363-8060
Practice Address - Fax:610-594-8448
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0E007863P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0167173415Medicaid