Provider Demographics
NPI:1295710515
Name:GORZ, JOHN EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:GORZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N 7881 WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-9699
Mailing Address - Country:US
Mailing Address - Phone:920-487-2077
Mailing Address - Fax:920-487-9770
Practice Address - Street 1:1021 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201-1737
Practice Address - Country:US
Practice Address - Phone:920-487-2020
Practice Address - Fax:920-487-5022
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1997152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38574100Medicaid
WI000247383OtherMEDICARE PTAN
WI38709200Medicaid
WI87472Medicare ID - Type Unspecified
WI38574100Medicaid
WI0371740001Medicare NSC
WI87724Medicare ID - Type Unspecified
WI38709200Medicaid
WI0371740002Medicare NSC