Provider Demographics
NPI:1952355034
Name:GRAYTOCK, KATHLEEN M (DPM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:GRAYTOCK
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 1:1660 NW PROFESSIONAL PLZ
Mailing Address - Street 2:SUITE K
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3854
Mailing Address - Country:US
Mailing Address - Phone:614-574-4774
Mailing Address - Fax:614-457-4795
Practice Address - Street 1:1660 NW PROFESSIONAL PLZ
Practice Address - Street 2:SUITE K
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3854
Practice Address - Country:US
Practice Address - Phone:614-574-4774
Practice Address - Fax:614-457-4795
Is Sole Proprietor?:No
Enumeration Date:2006-05-21
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002809G213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0932030Medicaid
OHGR0738674Medicare ID - Type Unspecified
OH0932030Medicaid