Healthcare Provider Details

I. General information

NPI: 1417997297
Provider Name (Legal Business Name): MICHAEL RICHARD GONDEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEALTH SERVICES - EDC THE DOW CHEMICAL CO
MIDLAND MI
48674-0001
US

IV. Provider business mailing address

4720 N VERITY RD
SANFORD MI
48657-9391
US

V. Phone/Fax

Practice location:
  • Phone: 989-636-9150
  • Fax:
Mailing address:
  • Phone: 989-687-6398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number43010432628
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: