Healthcare Provider Details

I. General information

NPI: 1235453994
Provider Name (Legal Business Name): MITALI A PAKVASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S GRANT AVE
COLUMBUS OH
43215-4701
US

IV. Provider business mailing address

285 E STATE STREET
COLUMBUS OH
43215-4354
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-9000
  • Fax:
Mailing address:
  • Phone: 614-566-9683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35.138675
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: