Healthcare Provider Details

I. General information

NPI: 1750597985
Provider Name (Legal Business Name): PAUL EDWARD GAWELKO D. O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20470 N LAKE PLEASANT RD STE 110
PEORIA AZ
85382-9708
US

IV. Provider business mailing address

2500 W UTOPIA RD STE. 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 623-266-4699
  • Fax: 623-825-5630
Mailing address:
  • Phone: 602-214-6148
  • Fax: 602-214-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4519
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: