Provider Demographics
NPI:1609912914
Name:BOZUK & ASSOCIATES SURGICAL, INC.
Entity Type:Organization
Organization Name:BOZUK & ASSOCIATES SURGICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:BOZUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-763-3967
Mailing Address - Street 1:1456 PROFESSIONAL DR
Mailing Address - Street 2:STE. #404
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6639
Mailing Address - Country:US
Mailing Address - Phone:707-763-3967
Mailing Address - Fax:707-765-0554
Practice Address - Street 1:1456 PROFESSIONAL DR
Practice Address - Street 2:STE. #404
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6639
Practice Address - Country:US
Practice Address - Phone:707-763-3967
Practice Address - Fax:707-765-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73703208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A737030Medicaid
CA00A737030Medicaid
CAI47149Medicare UPIN