1689770505 NPI number — DR. THERESA RUTH DISERIO PH.D.

Table of content: DR. THERESA RUTH DISERIO PH.D. (NPI 1689770505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689770505 NPI number — DR. THERESA RUTH DISERIO PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DISERIO
Provider First Name:
THERESA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAMSAY
Provider Other First Name:
THERESA
Provider Other Middle Name:
DISERIO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689770505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3831 ATTUCKS DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
POWELL
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43065-6082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-791-0799
Provider Business Mailing Address Fax Number:
614-791-0798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3831 ATTUCKS DR
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
POWELL
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43065-6082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-791-0799
Provider Business Practice Location Address Fax Number:
614-791-0798
Provider Enumeration Date:
09/16/2006

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: 103T00000X , with the licence number:  4337 , 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)





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