Provider Demographics
NPI:1497973143
Name:KURUVILLA, MARY (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:KURUVILLA
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 1:5070 PEBBLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322
Mailing Address - Country:US
Mailing Address - Phone:937-832-1320
Mailing Address - Fax:937-496-2943
Practice Address - Street 1:1520 GERMANTOWN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-1318
Practice Address - Country:US
Practice Address - Phone:937-222-8111
Practice Address - Fax:937-496-2943
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35056398OHIO2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2961166Medicaid
E76386Medicare UPIN