Provider Demographics
NPI:1790331080
Name:PAVEL GOZENPUT MEDICAL PC
Entity Type:Organization
Organization Name:PAVEL GOZENPUT MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOZENPUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-344-4474
Mailing Address - Street 1:2083 E 65TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5913
Mailing Address - Country:US
Mailing Address - Phone:718-444-5105
Mailing Address - Fax:718-444-5107
Practice Address - Street 1:2083 E 65TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5913
Practice Address - Country:US
Practice Address - Phone:718-444-5105
Practice Address - Fax:718-444-5107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty