Provider Demographics
NPI:1962452789
Name:GONIK, CHARLES OZAK (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:OZAK
Last Name:GONIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2520 S TELEGRAPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0285
Mailing Address - Country:US
Mailing Address - Phone:248-335-9207
Mailing Address - Fax:248-335-2394
Practice Address - Street 1:225 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-4616
Practice Address - Country:US
Practice Address - Phone:561-274-3100
Practice Address - Fax:561-837-5332
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69198207V00000X
MI4301045929207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4170036Medicaid
MI10-4170036Medicaid
MIA76981Medicare UPIN