1376500454 NPI number — DORIS ELAINE WALZAK MD

Table of content: DORIS ELAINE WALZAK MD (NPI 1376500454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376500454 NPI number — DORIS ELAINE WALZAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALZAK
Provider First Name:
DORIS
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376500454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 183103
Provider Second Line Business Mailing Address:
660 ACKERMAN 3RD FLOOR
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43218-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-293-2150
Provider Business Mailing Address Fax Number:
614-293-6479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
456 WEST TENTH AVENUE
Provider Second Line Business Practice Location Address:
CLINIC 3A 3D
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-293-8105
Provider Business Practice Location Address Fax Number:
614-293-4890
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35038032W , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0328792 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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