Provider Demographics
NPI:1508854654
Name:GONZABA, JOHN ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:GONZABA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0038
Mailing Address - Country:US
Mailing Address - Phone:812-738-4251
Mailing Address - Fax:
Practice Address - Street 1:1263 HOSPITAL DR NW STE 270
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2178
Practice Address - Country:US
Practice Address - Phone:812-738-4251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002543A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000295497OtherANTHEM
INP00102949OtherRR MEDICARE
IN200415240Medicaid
IN940190TTTMedicare ID - Type Unspecified
H78313Medicare UPIN