Provider Demographics
NPI:1780899633
Name:AMBALAVANAN, GEETHA C (MD)
Entity type:Individual
Prefix:
First Name:GEETHA
Middle Name:C
Last Name:AMBALAVANAN
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 1:2180 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6356
Mailing Address - Country:US
Mailing Address - Phone:937-208-8155
Mailing Address - Fax:937-208-8140
Practice Address - Street 1:2180 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6356
Practice Address - Country:US
Practice Address - Phone:937-208-8155
Practice Address - Fax:937-208-8140
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-089208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2781673Medicaid
OH4220521Medicare PIN
OH2781673Medicaid