Healthcare Provider Details

I. General information

NPI: 1609875392
Provider Name (Legal Business Name): GARY GAZELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8555 N SILVERY LN SUITE C302
DEARBORN HEIGHTS MI
48127-1379
US

IV. Provider business mailing address

8555 N SILVERY LN SUITE C302
DEARBORN HEIGHTS MI
48127-1379
US

V. Phone/Fax

Practice location:
  • Phone: 313-561-0550
  • Fax: 313-561-3646
Mailing address:
  • Phone: 313-561-0550
  • Fax: 313-561-3646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberGG034127
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: