Provider Demographics
NPI:1376610337
Name:GUDLESKI, MICHAEL OZLO (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:OZLO
Last Name:GUDLESKI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:ROBERT
Other - Last Name:GUDLESKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 STUYVESANT OVAL
Mailing Address - Street 2:APT 12A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-2424
Mailing Address - Country:US
Mailing Address - Phone:212-674-3536
Mailing Address - Fax:
Practice Address - Street 1:114 AND AMSTERDAM AVE
Practice Address - Street 2:ST LUKES HOSPITAL CONTUNUUM HEALTH
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009
Practice Address - Country:US
Practice Address - Phone:212-533-4446
Practice Address - Fax:212-523-4598
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025171 1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01773202Medicare ID - Type Unspecified