Provider Demographics
NPI:1164461372
Name:IMWALLE, DONALD KOLMAN (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:KOLMAN
Last Name:IMWALLE
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 1:1331 N ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6302
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-965-8041
Practice Address - Fax:513-965-8091
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350845792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2008517420AMedicaid
OH2738041Medicaid
OH4196991Medicare PIN
OH300012311Medicare PIN
OH2738041Medicaid
OHP00461300Medicare PIN