Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207N00000X | Dermatology | | | | No |
| 2 | 207Q00000X | Family Medicine | | | | Yes |
| 3 | 207QG0300X | Family Medicine | Geriatric Medicine | | | No |
| 4 | 207R00000X | Internal Medicine | | | | No |
| 5 | 207RE0101X | Internal Medicine | Endocrinology, Diabetes & Metabolism | | | No |
| 6 | 207RI0200X | Internal Medicine | Infectious Disease | | | No |
| 7 | 207RR0500X | Internal Medicine | Rheumatology | | | No |
| 8 | 207V00000X | Obstetrics & Gynecology | | | | No |
| 9 | 207VX0201X | Obstetrics & Gynecology | Gynecologic Oncology | | | No |
| 10 | 207X00000X | Orthopaedic Surgery | | | | No |
| 11 | 208000000X | Pediatrics | | | | No |
| 12 | 2080P0206X | Pediatrics | Pediatric Gastroenterology | | | No |
| 13 | 208200000X | Plastic Surgery | | | | No |
| 14 | 2084N0400X | Psychiatry & Neurology | Neurology | 821388 | OHIO | No |
| 15 | 208600000X | Surgery | | | | No |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 1316188147 | OTHER | | SURGERY DME SUBGROUP |
| 2 | 1295977254 | OTHER | | ASC DME NPI |
| 3 | 821388 | OTHER | OHIO | BUSINESS LICENSE |
| 4 | 0654700009 | OTHER | | NSC SUITE 5253 |
| 5 | 0914443 | MEDICAID | OHIO | |
| 6 | 1306087515 | OTHER | | NCS SUBPART PLSTC SURG 6257 |
| 7 | 3610562 | OTHER | | MEDICARE PTAN ASC |
| 8 | 10654700002 | OTHER | OHIO | MEDICARE DME PTAN |
| 9 | 1417133380 | OTHER | | ORTHO DME SUBGROUP |
| 10 | 1649447582 | OTHER | | ASC SUBGROUP |
| 11 | 1205197985 | OTHER | OHIO | SUBPART NPI DME MOB |
| 12 | 1215178421 | OTHER | | NSC SUBPART VASC SURG |
| 13 | 1427299841 | OTHER | | NCS SUBPARTSURG ONC |
