Healthcare Provider Details

I. General information

NPI: 1982793303
Provider Name (Legal Business Name): MARIANO FERNANDEZ-ULLOA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45267-1000
US

IV. Provider business mailing address

3200 BURNET AVE 3 SOUTH
CINCINNATI OH
45229-3019
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-2146
  • Fax: 513-584-0431
Mailing address:
  • Phone: 513-585-5501
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number35-04-0051-F
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: