Provider Demographics
NPI:1114251451
Name:MATHUR, DEEPA (MD)
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:MATHUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEEPA
Other - Middle Name:
Other - Last Name:KANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3845 ATTUCKS DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-6082
Mailing Address - Country:US
Mailing Address - Phone:614-553-7445
Mailing Address - Fax:
Practice Address - Street 1:3845 ATTUCKS DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-6082
Practice Address - Country:US
Practice Address - Phone:614-553-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH120275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077807Medicaid
OH0077807Medicaid