Provider Demographics
NPI:1952387052
Name:GONZALES, SUSAN V (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:V
Last Name:GONZALES
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 1:3101 BURNET AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3014
Mailing Address - Country:US
Mailing Address - Phone:513-357-7289
Mailing Address - Fax:513-357-7396
Practice Address - Street 1:1525 ELM STREET
Practice Address - Street 2:ELM STREET HEALTH CENTER
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45202-6957
Practice Address - Country:US
Practice Address - Phone:513-352-3092
Practice Address - Fax:513-352-1429
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074826207R00000X
OH35.074826208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2142676Medicaid
G98171Medicare UPIN
G02023721Medicare ID - Type Unspecified
OH2142676Medicaid
OH0879586Medicare PIN