Provider Demographics
NPI:1053379081
Name:KOZIELEC, GREGORY F (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:F
Last Name:KOZIELEC
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 1:3414 OAK GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2375
Mailing Address - Country:US
Mailing Address - Phone:214-521-1153
Mailing Address - Fax:214-219-3651
Practice Address - Street 1:3414 OAK GROVE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2375
Practice Address - Country:US
Practice Address - Phone:214-521-1153
Practice Address - Fax:214-219-3651
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0036-098036207W00000X, 207WX0107X
TXK9587207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168274001Medicaid
TX7909137OtherAETNA
TX8583K0OtherBCBS/GRP 00T587
TX180043890OtherRR MEDICARE GRP CJ5857
TX044052103Medicaid
TX044052101Medicaid
TX044052102Medicaid
TX044052101Medicaid
AR168274001Medicaid
TX8583K0Medicare PIN
TX8444M0Medicare PIN