Provider Demographics
NPI:1881799831
Name:GLOTH, FRED MICHAEL III (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:MICHAEL
Last Name:GLOTH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:MICHAEL
Other - Last Name:GLOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1441 HERITAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2260
Mailing Address - Country:US
Mailing Address - Phone:239-658-3117
Mailing Address - Fax:239-658-3074
Practice Address - Street 1:1441 HERITAGE BLVD
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2260
Practice Address - Country:US
Practice Address - Phone:239-658-3117
Practice Address - Fax:239-658-3074
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111776207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27554Medicare UPIN