1457759565 NPI number — GLADYS FAYE DOZIER MS, SAC

Table of content: GLADYS FAYE DOZIER MS, SAC (NPI 1457759565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457759565 NPI number — GLADYS FAYE DOZIER MS, SAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOZIER
Provider First Name:
GLADYS
Provider Middle Name:
FAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, SAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457759565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 W WELLS ST
Provider Second Line Business Mailing Address:
SUITE 312
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53203-1866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-344-3406
Provider Business Mailing Address Fax Number:
414-344-0107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 W WELLS ST
Provider Second Line Business Practice Location Address:
SUITE 312
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53203-1866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-344-3406
Provider Business Practice Location Address Fax Number:
414-344-0107
Provider Enumeration Date:
12/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  15893131 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1457759565 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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