Basic Information
| Provider Information | |||||||||
| NPI: | 1922236447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRNAROVA | ||||||||
| FirstName: | RISTENKA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 3006 N COUNTY ROAD 25A STE 104 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373353518 | ||||||||
| FaxNumber: | 9373326857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34.010757 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 5101018279 | MI | N | Allopathic & Osteopathic Physicians | General Practice | 207RC0000X | 34.010757 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0077430 | 05 | OH | MEDICAID |