Healthcare Provider Details

I. General information

NPI: 1962062067
Provider Name (Legal Business Name): CMDPN MEDICAL GROUP OF OHIO, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S 3RD ST STE 200
COLUMBUS OH
43215-5194
US

IV. Provider business mailing address

175 S 3RD ST STE 200
COLUMBUS OH
43215-5194
US

V. Phone/Fax

Practice location:
  • Phone: 720-996-0522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN DUTTON
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 916-215-4554