Healthcare Provider Details

I. General information

NPI: 1699191189
Provider Name (Legal Business Name): CHARLES GORODETZKY M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2014
Last Update Date: 03/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 WARD PKWY
KANSAS CITY MO
64112-2366
US

IV. Provider business mailing address

5005 WARD PKWY
KANSAS CITY MO
64112-2366
US

V. Phone/Fax

Practice location:
  • Phone: 816-813-4255
  • Fax:
Mailing address:
  • Phone: 816-813-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number14020
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: