Provider Demographics
NPI:1891774022
Name:CORDERO, GRETCHEN G (MD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:G
Last Name:CORDERO
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 1:700 ACKERMAN RD STE 570
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1579
Mailing Address - Country:US
Mailing Address - Phone:614-293-8315
Mailing Address - Fax:
Practice Address - Street 1:395 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-293-8315
Practice Address - Fax:614-293-6935
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350791912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2272973Medicaid
OHH42543Medicare UPIN
OHH42543Medicare UPIN
OH300126528OtherRR MEDICARE