Healthcare Provider Details

I. General information

NPI: 1407045164
Provider Name (Legal Business Name): CASEY JOHN MOOTHART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 WAYCROSS RD
CINCINNATI OH
45240-3022
US

IV. Provider business mailing address

924 WAYCROSS RD
CINCINNATI OH
45240-3022
US

V. Phone/Fax

Practice location:
  • Phone: 513-588-3623
  • Fax: 513-851-4800
Mailing address:
  • Phone: 513-588-3623
  • Fax: 513-851-4800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-093143
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-093143
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: