Provider Demographics
NPI:1336306141
Name:GAETA, MIGUEL M (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:M
Last Name:GAETA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1221
Mailing Address - Country:US
Mailing Address - Phone:937-395-6010
Mailing Address - Fax:937-395-8162
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-6010
Practice Address - Fax:937-395-8162
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241909208600000X
NH14547208600000X
DCMD037557208600000X
OH35.1284272086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0166016Medicaid
OH0166016Medicaid