Provider Demographics
NPI:1891166575
Name:KOZLOW EYE CENTER PLLC
Entity type:Organization
Organization Name:KOZLOW EYE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:KOZLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-626-0909
Mailing Address - Street 1:23874 KEAN STREET
Mailing Address - Street 2:#130
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1804
Mailing Address - Country:US
Mailing Address - Phone:313-626-0909
Mailing Address - Fax:313-551-5688
Practice Address - Street 1:23874 KEAN ST
Practice Address - Street 2:#130
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1804
Practice Address - Country:US
Practice Address - Phone:313-626-0909
Practice Address - Fax:313-551-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054436207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97090002Medicare PIN