Basic Information
| Provider Information | |||||||||
| NPI: | 1063470722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAMER | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PSY D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1670 UPHAM DR. | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142939600 | ||||||||
| FaxNumber: | 6142939467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1670 UPHAM DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142939600 | ||||||||
| FaxNumber: | 6142939467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 10/15/2009 | ||||||||
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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 | 103T00000X | 4095 | OH | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 2211814 | 05 | OH | MEDICAID |