Healthcare Provider Details

I. General information

NPI: 1679901649
Provider Name (Legal Business Name): MONCLOVA ROAD PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 MONCLOVA RD STE 10
MAUMEE OH
43537-1863
US

IV. Provider business mailing address

5757 MONCLOVA RD STE 10
MAUMEE OH
43537-1863
US

V. Phone/Fax

Practice location:
  • Phone: 419-887-0803
  • Fax: 419-887-0817
Mailing address:
  • Phone: 419-887-0803
  • Fax: 419-887-0817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATHRYN R DAVIS
Title or Position: OWNER
Credential: MD
Phone: 419-887-0803