Healthcare Provider Details

I. General information

NPI: 1790761989
Provider Name (Legal Business Name): EDNA SANTOS VIANZON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 W 3RD ST STE 102
DAYTON OH
45402-6848
US

IV. Provider business mailing address

PO BOX 933432
CLEVELAND OH
44193-0039
US

V. Phone/Fax

Practice location:
  • Phone: 937-268-3483
  • Fax: 937-268-1884
Mailing address:
  • Phone: 937-641-5072
  • Fax: 937-641-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35083899V
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: