Healthcare Provider Details

I. General information

NPI: 1710007125
Provider Name (Legal Business Name): TANYA L KOWALCZYK MULLINS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANYA L KOWALCZYK M.D.

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 4000
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE ML 4000
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4681
  • Fax: 513-636-8844
Mailing address:
  • Phone: 513-636-4681
  • Fax: 513-636-8844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number57.009118
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: