Healthcare Provider Details

I. General information

NPI: 1962820522
Provider Name (Legal Business Name): DR. MICHAEL IAN GAZES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 06/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CAMPBELL AVE VA CT HEALTHCARE SYSTEM - SURGICAL SERVICE/112
WEST HAVEN CT
06516-2770
US

IV. Provider business mailing address

330 ORCHARD STREET MOB 207
NEW HAVEN CT
06511
US

V. Phone/Fax

Practice location:
  • Phone: 203-932-5711
  • Fax:
Mailing address:
  • Phone: 203-789-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberN006822-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number950
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: