Provider Demographics
NPI:1629575048
Name:GERARDO, RODRIGO
Entity Type:Individual
Prefix:
First Name:RODRIGO
Middle Name:
Last Name:GERARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E. APPLE ST.
Mailing Address - Street 2:WCHE 7TH FLOOR
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 E. APPLE ST.
Practice Address - Street 2:WCHE 7TH FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-208-4953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.140753208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program