Provider Demographics
NPI:1104847516
Name:CHAPMAN, DEITRICE EILEEN (MD)
Entity Type:Individual
Prefix:
First Name:DEITRICE
Middle Name:EILEEN
Last Name:CHAPMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BUILDING B 3RD FLOOR
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:6611 CLYO RD
Practice Address - Street 2:STE B
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-2786
Practice Address - Country:US
Practice Address - Phone:937-208-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH326028833-00OtherBWC PROVIDER NUMBER
OH2016919Medicaid
OH0259191OtherWORKER'S COMP
OH0259191OtherWORKER'S COMP
OH2016919Medicaid
OH326028833-00OtherBWC PROVIDER NUMBER