Provider Demographics
NPI:1821389719
Name:IMHOF, KATIE CALAWAY (MD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:CALAWAY
Last Name:IMHOF
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 1:20 PRESTIGE PLAZA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-7303
Mailing Address - Country:US
Mailing Address - Phone:937-436-4658
Mailing Address - Fax:937-436-4984
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-436-4658
Practice Address - Fax:937-436-4984
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
OH35.121503207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH215720OtherMEDICARE PTAN
OHH207170OtherMEDICARE PTAN