Provider Demographics
NPI:1801298294
Name:VAN, MIMI T (DO)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:T
Last Name:VAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-6200
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:7675 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-2509
Practice Address - Country:US
Practice Address - Phone:513-475-7505
Practice Address - Fax:513-475-8898
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13825207R00000X
AZ7793207RG0100X
NMDO2023-1014207RG0100X
OH34.017575207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine