Provider Demographics
NPI:1689255028
Name:KOZAK, MARY ELIZABETH COPELAND (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH COPELAND
Last Name:KOZAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:COPELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:375 N WALL ST STE P310
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3484
Mailing Address - Country:US
Mailing Address - Phone:815-933-0194
Mailing Address - Fax:
Practice Address - Street 1:375 N WALL ST STE P310
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3484
Practice Address - Country:US
Practice Address - Phone:815-933-0194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036166884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine