Healthcare Provider Details

I. General information

NPI: 1699954255
Provider Name (Legal Business Name): KIDZ FIRST PEDIATRICS OF OBERLIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12289 LEAVITT RD UNIT D
OBERLIN OH
44074-8500
US

IV. Provider business mailing address

12289 LEAVITT RD UNIT D
OBERLIN OH
44074-8500
US

V. Phone/Fax

Practice location:
  • Phone: 440-775-1555
  • Fax:
Mailing address:
  • Phone: 440-775-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.006510
License Number StateOH

VIII. Authorized Official

Name: DR. JOHN R SANDERSON
Title or Position: PRESIDENT
Credential: D.O.
Phone: 440-775-1555