Healthcare Provider Details

I. General information

NPI: 1558599381
Provider Name (Legal Business Name): PAVEL GOZENPUT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEALTHY WAY
OCEANSIDE NY
11572
US

IV. Provider business mailing address

247 WHITMAN DR
BROOKLYN NY
11234-6934
US

V. Phone/Fax

Practice location:
  • Phone: 516-632-3200
  • Fax:
Mailing address:
  • Phone: 718-344-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number265898
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number265898
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number265898
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: