=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104864891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRELA CRISAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 06/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 W BROAD ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43222-1054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-205-4596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4063 FAIRFAX DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43220-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-256-6855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35-08-3853-C
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------