Provider Demographics
NPI:1043597404
Name:TATUM, MOLLY A (DO)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:A
Last Name:TATUM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MOLLY
Other - Middle Name:A
Other - Last Name:MCGRAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-713-1779
Mailing Address - Fax:138-549-9215
Practice Address - Street 1:3205 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1143
Practice Address - Country:US
Practice Address - Phone:937-298-4417
Practice Address - Fax:937-298-8260
Is Sole Proprietor?:No
Enumeration Date:2011-11-12
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012776207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0236490Medicaid