Provider Demographics
NPI:1437224508
Name:MARDOVIN, VLADA W (MD)
Entity Type:Individual
Prefix:
First Name:VLADA
Middle Name:W
Last Name:MARDOVIN
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 1:1164 E HOME RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2726
Mailing Address - Country:US
Mailing Address - Phone:937-342-9260
Mailing Address - Fax:937-342-9262
Practice Address - Street 1:1164 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2726
Practice Address - Country:US
Practice Address - Phone:937-342-9260
Practice Address - Fax:937-342-9262
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069608174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMA4047453OtherOTHER MEDICARE LOCATION
1900693OtherUNITED HEALTHCARE
OH0007490231OtherAETNA
OH0267358Medicaid
340018970OtherRR MEDICARE
OH0007490231OtherAETNA
OHMA4047452Medicare PIN
OHMA0824209Medicare PIN