Healthcare Provider Details

I. General information

NPI: 1376610337
Provider Name (Legal Business Name): MICHAEL OZLO GUDLESKI PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL ROBERT GUDLESKI

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 AND AMSTERDAM AVE ST LUKES HOSPITAL CONTUNUUM HEALTH
NEW YORK NY
10009
US

IV. Provider business mailing address

10 STUYVESANT OVAL APT 12A
NEW YORK NY
10009-2424
US

V. Phone/Fax

Practice location:
  • Phone: 212-533-4446
  • Fax: 212-523-4598
Mailing address:
  • Phone: 212-674-3536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number025171 1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: