Provider Demographics
NPI:1407045164
Name:MOOTHART, CASEY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:JOHN
Last Name:MOOTHART
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 1:924 WAYCROSS RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-3022
Mailing Address - Country:US
Mailing Address - Phone:513-588-3623
Mailing Address - Fax:513-851-4800
Practice Address - Street 1:924 WAYCROSS RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-3022
Practice Address - Country:US
Practice Address - Phone:513-588-3623
Practice Address - Fax:513-851-4800
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-093143208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2937479Medicaid
OHH443681Medicare PIN