Provider Demographics
NPI:1568456630
Name:MOELLER, DONNALYN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DONNALYN
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1306
Mailing Address - Country:US
Mailing Address - Phone:614-272-8854
Mailing Address - Fax:614-272-9200
Practice Address - Street 1:3131 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1306
Practice Address - Country:US
Practice Address - Phone:614-272-8854
Practice Address - Fax:614-272-9200
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3600995213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2015125Medicaid
U66953Medicare UPIN
OH2015125Medicaid
M00829106Medicare ID - Type Unspecified