=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255472494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM MICHAEL GAZDAR D.C. C.C.S.P.,Q.M.E.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 YGNACIO VALLEY RD SUITE C-204
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94598-3391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-939-2225
-----------------------------------------------------
Fax | 925-939-8017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 YGNACIO VALLEY RD SUITE C-204
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94598-3391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-939-2225
-----------------------------------------------------
Fax | 925-939-8017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | DC 20466
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------