Healthcare Provider Details

I. General information

NPI: 1497973143
Provider Name (Legal Business Name): MARY KURUVILLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 GERMANTOWN ST
DAYTON OH
45408-1318
US

IV. Provider business mailing address

5070 PEBBLEBROOK DR
ENGLEWOOD OH
45322
US

V. Phone/Fax

Practice location:
  • Phone: 937-222-8111
  • Fax: 937-496-2943
Mailing address:
  • Phone: 937-832-1320
  • Fax: 937-496-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35056398OHIO
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: