Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | BM015681 | MI |
N | 207ND0101X | MOHS-Micrographic Surgeon | BM015681 | MI |
N | 207NP0225X | Pediatric Dermatologist | BM015681 | MI |
N | 207NS0135X | Procedural Dermatology | BM015681 | MI |
Y | 207Q00000X | Family Doctor | BM015681 | MI |
N | 207QA0505X | Family Doctor - Adult Medicine | BM015681 | MI |
NPI | 1215019682 |
---|---|
Provider Name | Dr. Robyn D Gazall |
First Address | Grand Ledge, MI 48837-2223 |
Second Address | Lansing, MI 48910-3495 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2006 |
Last Update Date | 12/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5101015681 | MI STATE LICENSE (01) | MI |
5315027997 | CONTROLLED SUBSTANCE (01) | MI |
BM9949910 | DEA LICENSE (01) | MI |