Provider Demographics
NPI:1407588817
Name:GOZDOR, JACOB DAVID
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DAVID
Last Name:GOZDOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10106 DORCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-2192
Mailing Address - Country:US
Mailing Address - Phone:248-568-1886
Mailing Address - Fax:
Practice Address - Street 1:707 N ALVERNON WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1827
Practice Address - Country:US
Practice Address - Phone:989-583-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIG235356135366390200000X
AZR80915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program