Basic Information
| Provider Information | |||||||||
| NPI: | 1649645300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIOARA TUDOSIE, MD, LLC | ||||||||
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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: | 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 | ||||||||
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| AuthorizedOfficialLastName: | TUDOSIE | ||||||||
| AuthorizedOfficialFirstName: | MIOARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3304551511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| 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 |