Healthcare Provider Details

I. General information

NPI: 1821141250
Provider Name (Legal Business Name): SHOLOM GOOTZEIT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17233 N HOLMES BLVD STE 1640 13761 W. BELL ROAD, SUITE 203, SURPRISE, AZ 85374
PHOENIX AZ
85053-2020
US

IV. Provider business mailing address

13757 W BELL RD STE 101
SURPRISE AZ
85374-2452
US

V. Phone/Fax

Practice location:
  • Phone: 602-467-8682
  • Fax:
Mailing address:
  • Phone: 623-214-7600
  • Fax: 623-214-7600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number005463
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number005463
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: