Provider Demographics
NPI:1922212638
Name:GOTTFRIED, RHODA JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RHODA
Middle Name:JEAN
Last Name:GOTTFRIED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3024 E EMPIRE ST
Mailing Address - Street 2:2ND FLOOR SUITE A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-5402
Mailing Address - Country:US
Mailing Address - Phone:309-556-7800
Mailing Address - Fax:309-556-7804
Practice Address - Street 1:3024 E EMPIRE ST
Practice Address - Street 2:2ND FLOOR SUITE A
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-5402
Practice Address - Country:US
Practice Address - Phone:309-556-7800
Practice Address - Fax:309-556-7804
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036.1318252084P0804X
CAA939072084P0804X
MDD00665672084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD036482700Medicaid
MD192272Y8KMedicare PIN