Basic Information
| Provider Information | |||||||||
| NPI: | 1336255884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUDOSIE | ||||||||
| FirstName: | MIOARA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4347 PORTAGE ST NW STE 102 | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005270336 | ||||||||
| FaxNumber: | 3302448521 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 WEST TUSCARAWAS ST | ||||||||
| Address2: | SUITE 640 | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304551511 | ||||||||
| FaxNumber: | 3304555028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35063127 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0914210 | 05 | OH | MEDICAID |