Healthcare Provider Details

I. General information

NPI: 1164513594
Provider Name (Legal Business Name): KIMBERLY WASCAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

2950 ROBERTSON AVE 2ND FLOOR
CINCINNATI OH
45209-1268
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-3356
  • Fax: 513-281-4545
Mailing address:
  • Phone: 513-281-4400
  • Fax: 513-281-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35-084900
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: