Healthcare Provider Details

I. General information

NPI: 1013091669
Provider Name (Legal Business Name): GWEN MARIE BROZ DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 N MAIN ST
W BROOKFIELD MA
01585
US

IV. Provider business mailing address

PO BOX 1044
W BROOKFIELD MA
01585
US

V. Phone/Fax

Practice location:
  • Phone: 508-867-8977
  • Fax: 508-867-7361
Mailing address:
  • Phone: 508-867-8977
  • Fax: 508-867-7361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73319
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: