Basic Information
| Provider Information | |||||||||
| NPI: | 1942264171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOZLEK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-0698 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911100698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631618 | ||||||||
| Practice Location | |||||||||
| Address1: | 4212 N 16TH ST | ||||||||
| Address2: | PHOENIX INDIAN MEDICAL CENTER | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850165319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 4301093278 | MI | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | MD009965E | PA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 000604893 | 05 | PA | MEDICAID | 0F96004 | 01 | MI | GROUP MEDICARE ID NUMBER | OTHER | 867633 | 01 | GROUP MEDICARE # | OTHER | MD009965E | 01 | PA | MEDICAL LICENSE | OTHER | AK9631739 | 01 | PA | DEA | OTHER |