Basic Information
| Provider Information | |||||||||
| NPI: | 1437224508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARDOVIN | ||||||||
| FirstName: | VLADA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1164 E HOME RD | ||||||||
| Address2: | SUITE J | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455032726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373429260 | ||||||||
| FaxNumber: | 9373429262 | ||||||||
| Practice Location | |||||||||
| Address1: | 1164 E HOME RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455032726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373429260 | ||||||||
| FaxNumber: | 9373429262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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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 | 174400000X | 35069608 | OH | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | MA4047453 | 01 | OH | OTHER MEDICARE LOCATION | OTHER | 1900693 | 01 | UNITED HEALTHCARE | OTHER | 0007490231 | 01 | OH | AETNA | OTHER | 0267358 | 05 | OH | MEDICAID | 340018970 | 01 | RR MEDICARE | OTHER |