Provider Demographics
NPI:1346378510
Name:BENJAMIN S GOZON MD SC
Entity Type:Organization
Organization Name:BENJAMIN S GOZON MD SC
Other - Org Name:CAPITOL REHABILITATION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOZON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:414-464-4888
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42976261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34058300Medicaid
WI000101951Medicare ID - Type UnspecifiedDR. BENJAMIN GOZON, MD
WI34058300Medicaid