Provider Demographics
NPI:1699191189
Name:GORODETZKY, CHARLES (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:GORODETZKY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 WARD PKWY
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-2366
Mailing Address - Country:US
Mailing Address - Phone:816-813-4255
Mailing Address - Fax:
Practice Address - Street 1:5005 WARD PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64112-2366
Practice Address - Country:US
Practice Address - Phone:816-813-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14020208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology