Provider Demographics
NPI:1992792105
Name:PICKENS, CYNTHIA LORRAINE (MD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:LORRAINE
Last Name:PICKENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3033 KETTERING BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1962
Mailing Address - Country:US
Mailing Address - Phone:937-293-2133
Mailing Address - Fax:937-293-2161
Practice Address - Street 1:3033 KETTERING BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1962
Practice Address - Country:US
Practice Address - Phone:937-293-2133
Practice Address - Fax:937-293-2161
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35064390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0930069Medicaid
OH0930069Medicaid