Provider Demographics
NPI:1508494568
Name:GORSKI, MICHAEL R (RD, CD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:GORSKI
Suffix:
Gender:M
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GATSBY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-2255
Mailing Address - Country:US
Mailing Address - Phone:651-336-8962
Mailing Address - Fax:
Practice Address - Street 1:701 GATSBY GLEN DR
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-2255
Practice Address - Country:US
Practice Address - Phone:651-336-8962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86028466133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered