Provider Demographics
NPI:1255387841
Name:PODACH, DANITA M (PAC)
Entity type:Individual
Prefix:
First Name:DANITA
Middle Name:M
Last Name:PODACH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-2080
Practice Address - Country:US
Practice Address - Phone:419-673-8689
Practice Address - Fax:419-673-9492
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0092949Medicaid
H0969361Medicare PIN
OH0092949Medicaid
P59030Medicare UPIN