Provider Demographics
NPI:1659351229
Name:RODRIGUEZ, GONZALO J (MD)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:J
Last Name:RODRIGUEZ
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 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:3130 N COUNTY ROAD 25A STE 212
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373
Practice Address - Country:US
Practice Address - Phone:937-335-1660
Practice Address - Fax:937-440-4020
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01079320A207V00000X
MI4301067013207V00000X
OH35.069702207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300007805Medicaid
IN236040248OtherMEDICARE PTAN
MI3213148Medicaid
IN236040248OtherMEDICARE PTAN
IN300007805Medicaid