Provider Demographics
NPI:1154314334
Name:GONZAGA, AURORA (MD)
Entity Type:Individual
Prefix:MRS
First Name:AURORA
Middle Name:
Last Name:GONZAGA
Suffix:
Gender:F
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:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:MOGADORE
Mailing Address - State:OH
Mailing Address - Zip Code:44260-0367
Mailing Address - Country:US
Mailing Address - Phone:330-628-1325
Mailing Address - Fax:
Practice Address - Street 1:195 WADSWORTH RD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-9504
Practice Address - Country:US
Practice Address - Phone:330-334-2863
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35032393174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0137248Medicaid
OH0137248Medicaid