Provider Demographics
NPI:1922395763
Name:GURTIZEN, JEFFREY DAVID (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:GURTIZEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:779-696-7342
Practice Address - Street 1:4282 E ROCKTON RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073
Practice Address - Country:US
Practice Address - Phone:779-696-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014384207Q00000X
IL036-136236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400170064Medicare PIN