Healthcare Provider Details

I. General information

NPI: 1790762904
Provider Name (Legal Business Name): JOAN E WURMBRAND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 POLARIS PKWY STE 110
COLUMBUS OH
43240-4042
US

IV. Provider business mailing address

1120 POLARIS PKWY STE 110
COLUMBUS OH
43240-4042
US

V. Phone/Fax

Practice location:
  • Phone: 614-797-0600
  • Fax: 614-259-0610
Mailing address:
  • Phone: 614-797-0600
  • Fax: 614-259-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-04-5407
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: