Healthcare Provider Details

I. General information

NPI: 1588870323
Provider Name (Legal Business Name): EVAN JOHN WUTHRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WEST 10TH AVENUE JAMES CANCER CENTER, DEPARTMENT OF RADIATION ONCOLOGY
COLUMBUS OH
43210
US

IV. Provider business mailing address

3931 NEWHALL RD
UPPER ARLINGTON OH
43220-4865
US

V. Phone/Fax

Practice location:
  • Phone: 614-366-3886
  • Fax:
Mailing address:
  • Phone: 614-824-2439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT188837
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number35.097860
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: