Provider Demographics
NPI:1730199522
Name:SEROTA, GRETCHEN OLYMPIA (MD)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:OLYMPIA
Last Name:SEROTA
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:PO BOX 701830
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45270-0001
Mailing Address - Country:US
Mailing Address - Phone:513-474-9800
Mailing Address - Fax:513-474-9805
Practice Address - Street 1:5948 TURPIN VALLEY LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-3863
Practice Address - Country:US
Practice Address - Phone:513-474-9800
Practice Address - Fax:513-474-9805
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35067381207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0381546Medicaid
OH0813544Medicare PIN
OH0381546Medicaid