Provider Demographics
NPI:1346265493
Name:DOUDNA, PHILLIP B (BS, DC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:B
Last Name:DOUDNA
Suffix:
Gender:M
Credentials:BS, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-3017
Mailing Address - Country:US
Mailing Address - Phone:614-875-1121
Mailing Address - Fax:614-875-1111
Practice Address - Street 1:4305 BROADWAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-3017
Practice Address - Country:US
Practice Address - Phone:614-875-1121
Practice Address - Fax:614-875-1111
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31-1278375-00OtherBWC
OH0877538Medicaid
OH31-1278375-00OtherBWC
OH0639421Medicare ID - Type Unspecified