Provider Demographics
NPI:1265493431
Name:LASH, DOMINIQUE (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:LASH
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 1:5800 MONROE ST BLDG A
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2263
Mailing Address - Country:US
Mailing Address - Phone:419-885-8449
Mailing Address - Fax:419-882-7621
Practice Address - Street 1:5800 MONROE ST BLDG A
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2263
Practice Address - Country:US
Practice Address - Phone:419-885-8449
Practice Address - Fax:419-882-7621
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35092213208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633786OtherBLUE SHIELD NUMBER
IL036110742Medicaid
IL036110742Medicaid
IL206104Medicare ID - Type Unspecified