Healthcare Provider Details

I. General information

NPI: 1548721616
Provider Name (Legal Business Name): FRED PETE GONZALES III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 AUBURN AVE STE 724
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

2139 AUBURN AVE # 4-7
CINCINNATI OH
45219-2906
US

V. Phone/Fax

Practice location:
  • Phone: 513-241-4774
  • Fax:
Mailing address:
  • Phone: 513-558-7651
  • Fax: 513-558-7622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.249175
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35.151147
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: