Provider Demographics
NPI:1013091669
Name:BROZ, GWEN MARIE (DO)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MARIE
Last Name:BROZ
Suffix:
Gender:F
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 1044
Mailing Address - Street 2:
Mailing Address - City:W BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01585
Mailing Address - Country:US
Mailing Address - Phone:508-867-8977
Mailing Address - Fax:508-867-7361
Practice Address - Street 1:46 N MAIN ST
Practice Address - Street 2:
Practice Address - City:W BROOKFIELD
Practice Address - State:MA
Practice Address - Zip Code:01585
Practice Address - Country:US
Practice Address - Phone:508-867-8977
Practice Address - Fax:508-867-7361
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9787364Medicaid
E76658Medicare UPIN
MAM17858Medicare ID - Type Unspecified