Healthcare Provider Details

I. General information

NPI: 1457589087
Provider Name (Legal Business Name): JOHN TYCHONIEVICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 WELCOME PL
COLUMBUS OH
43209-7813
US

IV. Provider business mailing address

5350 FRANTZ RD
DUBLIN OH
43016-4259
US

V. Phone/Fax

Practice location:
  • Phone: 614-533-6800
  • Fax: 614-338-8735
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number121624
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: