Healthcare Provider Details

I. General information

NPI: 1174839401
Provider Name (Legal Business Name): GERARDO MANUEL HEREDIA MELERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11123 PARKVIEW PLAZA DR STE 102
FORT WAYNE IN
46845-1707
US

IV. Provider business mailing address

125 E MAXWELL ST STE 300
LEXINGTON KY
40508-2678
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-5240
  • Fax: 260-425-5245
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number50803
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number01099156A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number50803
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: