Provider Demographics
NPI:1306902580
Name:GOZDALSKI, WITOLD T (DC)
Entity type:Individual
Prefix:
First Name:WITOLD
Middle Name:T
Last Name:GOZDALSKI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 W IRVING PARK RD
Mailing Address - Street 2:STE. #301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2410
Mailing Address - Country:US
Mailing Address - Phone:773-282-4300
Mailing Address - Fax:773-282-4301
Practice Address - Street 1:6615 W IRVING PARK RD
Practice Address - Street 2:STE. #301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2410
Practice Address - Country:US
Practice Address - Phone:773-282-4300
Practice Address - Fax:773-282-4301
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00258667Medicare ID - Type UnspecifiedRAILROAD MEDICARE
ILK02496Medicare PIN