Provider Demographics
NPI:1073508503
Name:GOOZDICH, MITCHELL III (DC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:GOOZDICH
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1110
Mailing Address - Country:US
Mailing Address - Phone:440-985-5505
Mailing Address - Fax:440-985-5507
Practice Address - Street 1:113 N LEAVITT RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1110
Practice Address - Country:US
Practice Address - Phone:440-985-5505
Practice Address - Fax:440-985-5507
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDC.2965111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00004067OtherRAILROAD MEDICARE
OH2204715Medicaid
4401426OtherUNITED HEALTHCARE
OH000000257051OtherANTHEM BLUE CROSS
7757699OtherCIGNA
7757699OtherCIGNA
4031373Medicare ID - Type Unspecified