Basic Information
Provider Information | |||||||||
NPI: | 1649645300 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIOARA TUDOSIE, MD, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4347 PORTAGE ST NW STE 102 | ||||||||
Address2: |   | ||||||||
City: | NORTH CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447207371 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005270336 | ||||||||
FaxNumber: | 3302448505 | ||||||||
Practice Location | |||||||||
Address1: | 2600 TUSCARAWAS ST W | ||||||||
Address2: | SUITE 640 | ||||||||
City: | CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447084644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304551511 | ||||||||
FaxNumber: | 3304555028 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2015 | ||||||||
LastUpdateDate: | 04/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TUDOSIE | ||||||||
AuthorizedOfficialFirstName: | MIOARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3304551511 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0152782 | 05 | OH |   | MEDICAID |