Healthcare Provider Details

I. General information

NPI: 1912908096
Provider Name (Legal Business Name): THOMAS MICHAEL GUDEWICZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL, CAMP PENDLETON BLDG H100, SANTA MARGARITA ROAD ATTENTION: CODE CS-PA
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

4679 TELESCOPE AVE
CARLSBAD CA
92008-3766
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-0074
  • Fax: 760-725-1190
Mailing address:
  • Phone: 760-720-1878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA44176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: