Provider Demographics
NPI:1992709497
Name:GVOZDEN, PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:GVOZDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15906-2331
Mailing Address - Country:US
Mailing Address - Phone:814-809-7130
Mailing Address - Fax:814-809-7131
Practice Address - Street 1:128 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15906-2331
Practice Address - Country:US
Practice Address - Phone:814-809-7130
Practice Address - Fax:814-809-7131
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069402L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017589700005Medicaid
PA028823Medicare PIN
PA0017589700005Medicaid