Provider Demographics
NPI:1861831075
Name:MYCHAK, ASHLEY (DPM)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:MYCHAK
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 1:3373 COMMERCE PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-7130
Mailing Address - Country:US
Mailing Address - Phone:330-804-9712
Mailing Address - Fax:330-804-9811
Practice Address - Street 1:3373 COMMERCE PKWY STE 2
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-7130
Practice Address - Country:US
Practice Address - Phone:330-804-9712
Practice Address - Fax:330-804-9811
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003866213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0262019Medicaid