Healthcare Provider Details

I. General information

NPI: 1417924549
Provider Name (Legal Business Name): GAYLA N. ZOGHLIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26850 PROVIDENCE PKWY SUITE 370
NOVI MI
48374-1213
US

IV. Provider business mailing address

26850 PROVIDENCE PKWY SUITE 370
NOVI MI
48374-1213
US

V. Phone/Fax

Practice location:
  • Phone: 248-465-4160
  • Fax: 248-465-4525
Mailing address:
  • Phone: 248-465-4160
  • Fax: 248-465-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301046276
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: