Provider Demographics
NPI:1093794018
Name:MUTEMA, GEORGE K (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:K
Last Name:MUTEMA
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:PO BOX 632242
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2242
Mailing Address - Country:US
Mailing Address - Phone:800-503-6254
Mailing Address - Fax:
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-872-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077898207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64026404Medicaid
P00038444OtherRAILROAD MEDICARE
IN200453110DMedicaid
IN200453110EMedicaid
IN200453110FMedicaid
IN200453110CMedicaid
IN200453110AMedicaid
OH2183480Medicaid
OHMU4024574Medicare ID - Type Unspecified
IN200453110FMedicaid
IN200453110EMedicaid
IN200453110CMedicaid
OH2183480Medicaid