Provider Demographics
NPI:1336673037
Name:GERARDOT, JOHNNY LEE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:LEE
Last Name:GERARDOT
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3245 HEALTH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:
Practice Address - Street 1:6913 N MAIN ST
Practice Address - Street 2:STE 300
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8039
Practice Address - Country:US
Practice Address - Phone:574-647-1500
Practice Address - Fax:574-647-2567
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2023-05-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01084004A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300003090Medicaid