Basic Information
| Provider Information | |||||||||
| NPI: | 1063467090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DASENBROCK | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 DUPONT CIRCLE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135767700 | ||||||||
| FaxNumber: | 5135761020 | ||||||||
| Practice Location | |||||||||
| Address1: | 4357 FERGUSON DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452451689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137532820 | ||||||||
| FaxNumber: | 5137532424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35030286 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0257832 | 05 | OH | MEDICAID |