Provider Demographics
NPI:1376385385
Name:GOCKMAN, KELSEY (BS, MD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GOCKMAN
Suffix:
Gender:F
Credentials:BS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31298 SPRINGLAKE BLVD APT 1106
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1137
Mailing Address - Country:US
Mailing Address - Phone:224-422-9928
Mailing Address - Fax:
Practice Address - Street 1:14700 E OLD US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1185
Practice Address - Country:US
Practice Address - Phone:734-475-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351052390390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program