Provider Demographics
NPI:1457928970
Name:GAWLAK, JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:GAWLAK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:919 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-3717
Practice Address - Country:US
Practice Address - Phone:219-836-7531
Practice Address - Fax:219-836-7593
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004646A207P00000X, 363A00000X
IL085.009464363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-009464OtherLICENSE