Provider Demographics
NPI:1063467090
Name:DASENBROCK, RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
Last Name:DASENBROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 DUPONT CIRCLE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150
Mailing Address - Country:US
Mailing Address - Phone:513-576-7700
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:4357 FERGUSON DR
Practice Address - Street 2:SUITE 150
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1689
Practice Address - Country:US
Practice Address - Phone:513-753-2820
Practice Address - Fax:513-753-2424
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35030286208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0257832Medicaid
OHE65492Medicare UPIN
OHDA0674096Medicare PIN