Provider Demographics
NPI:1558302760
Name:KOZOLL, RICHARD LANDE (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LANDE
Last Name:KOZOLL
Suffix:
Gender:M
Credentials:MD, MPH
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 638
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:NM
Mailing Address - Zip Code:87013-0638
Mailing Address - Country:US
Mailing Address - Phone:505-289-3291
Mailing Address - Fax:505-289-0025
Practice Address - Street 1:6362 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NM
Practice Address - Zip Code:87013
Practice Address - Country:US
Practice Address - Phone:505-289-3326
Practice Address - Fax:505-289-3390
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM72-173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26013Medicaid
NMC97902Medicare UPIN