Provider Demographics
NPI:1528087913
Name:KOZLOV, DAVID BRADLEY (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRADLEY
Last Name:KOZLOV
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 1:1322 TUNEBERG PKWY
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-7902
Mailing Address - Country:US
Mailing Address - Phone:847-445-4262
Mailing Address - Fax:
Practice Address - Street 1:1322 TUNEBERG PKWY
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-7902
Practice Address - Country:US
Practice Address - Phone:847-445-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA318142085R0204X
WI43507-0202085R0204X
IL036-1004832085R0204X
FLME1059532085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212545OtherGROUP PTAN
IL202926OtherGROUP PTAN
IL036100483Medicaid
IL212545OtherGROUP PTAN
IL036100483Medicaid
212545004Medicare PIN