Provider Demographics
NPI:1669433066
Name:BENJAMIN S GOZON MD SC
Entity type:Organization
Organization Name:BENJAMIN S GOZON MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOZON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:414-464-4888
Mailing Address - Street 1:8518 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1827
Mailing Address - Country:US
Mailing Address - Phone:414-464-4888
Mailing Address - Fax:414-464-1850
Practice Address - Street 1:8518 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1827
Practice Address - Country:US
Practice Address - Phone:414-464-4888
Practice Address - Fax:414-464-1850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21285100Medicaid
WI21285100Medicaid