Provider Demographics
NPI:1033170428
Name:GOZON, BENJAMIN S III (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:S
Last Name:GOZON
Suffix:III
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 1:8518 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1827
Mailing Address - Country:US
Mailing Address - Phone:414-464-4888
Mailing Address - Fax:414-464-1850
Practice Address - Street 1:8518 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1827
Practice Address - Country:US
Practice Address - Phone:414-464-4888
Practice Address - Fax:414-464-1850
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42976208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34058300Medicaid
WI000101951Medicare ID - Type Unspecified
WI34058300Medicaid