Healthcare Provider Details

I. General information

NPI: 1174915987
Provider Name (Legal Business Name): OLGA DEMIDOVA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37045 CHAGRIN BLVD
MORELAND HILLS OH
44022-1238
US

IV. Provider business mailing address

37045 CHAGRIN BLVD
MORELAND HILLS OH
44022-1238
US

V. Phone/Fax

Practice location:
  • Phone: 216-804-5996
  • Fax: 216-758-4783
Mailing address:
  • Phone: 216-804-5996
  • Fax: 216-758-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS14719
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberOS14719
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number34.01294
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number34.012494
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: