Healthcare Provider Details

I. General information

NPI: 1467807321
Provider Name (Legal Business Name): BIJAN KETABCHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE. ML2008
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

MLC 5021 3333 BURNET AVE
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-7966
  • Fax: 513-636-7967
Mailing address:
  • Phone: 513-636-4225
  • Fax: 513-636-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.136411
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: