Basic Information
| Provider Information | |||||||||
| NPI: | 1962452789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONIK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | OZAK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 S TELEGRAPH RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483020285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483359207 | ||||||||
| FaxNumber: | 2483352394 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 S CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334454616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612743100 | ||||||||
| FaxNumber: | 5618375332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 04/11/2014 | ||||||||
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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 | 207V00000X | ME69198 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 4301045929 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 10-4170036 | 05 | MI | MEDICAID |