Provider Demographics
NPI:1548476120
Name:GATZIMOS, ALEXANDER C (MD,JD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:C
Last Name:GATZIMOS
Suffix:
Gender:M
Credentials:MD,JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WEST EDISON ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545
Mailing Address - Country:US
Mailing Address - Phone:574-222-2359
Mailing Address - Fax:574-222-2365
Practice Address - Street 1:212 WEST EDISON ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-222-2359
Practice Address - Fax:574-222-2365
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036818A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100063840BMedicaid
IN100063840BMedicaid