Healthcare Provider Details

I. General information

NPI: 1760862114
Provider Name (Legal Business Name): JEREMIAH GADDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WRIGHT PAT OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-0770
  • Fax: 937-257-0770
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.135023
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: