Basic Information
| Provider Information | |||||||||
| NPI: | 1669430252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOZA | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 KANIS RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012021902 | ||||||||
| FaxNumber: | 5012021512 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 KANIS RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012021902 | ||||||||
| FaxNumber: | 5012021512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | C5601 | AR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084S0012X | C-5601 | AR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101846001 | 05 | AR | MEDICAID |