Provider Demographics
NPI:1164635652
Name:OZOG, KRISTEN AMY (PT)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:AMY
Last Name:OZOG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 WALTON STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-1230
Mailing Address - Country:US
Mailing Address - Phone:315-478-0380
Mailing Address - Fax:315-478-0388
Practice Address - Street 1:419 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350
Practice Address - Country:US
Practice Address - Phone:315-717-0278
Practice Address - Fax:315-717-0280
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028440-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0172OtherMCR GRP
NY1710923222OtherNPI GRP
NYAA0171OtherMCR GROUP
NY02052091Medicaid