Provider Demographics
NPI:1700010840
Name:GOZDZIALSKI, THEODORE JOHN (RN)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHN
Last Name:GOZDZIALSKI
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:GOZDZIALSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:5062 IRONSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1637
Mailing Address - Country:US
Mailing Address - Phone:248-623-2615
Mailing Address - Fax:
Practice Address - Street 1:5062 IRONSIDE DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-1637
Practice Address - Country:US
Practice Address - Phone:248-623-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704106174163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice