Provider Demographics
NPI:1639522352
Name:KATOCH, GYPSA
Entity Type:Individual
Prefix:
First Name:GYPSA
Middle Name:
Last Name:KATOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 SAINT ANTOINE ST # 5B
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-1741
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST STE 5B
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-1741
Practice Address - Fax:313-745-8165
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301500191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301110120OtherMI STATE LICENSE