Provider Demographics
NPI:1982793303
Name:FERNANDEZ-ULLOA, MARIANO (MD)
Entity Type:Individual
Prefix:
First Name:MARIANO
Middle Name:
Last Name:FERNANDEZ-ULLOA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 BURNET AVE
Mailing Address - Street 2:3 SOUTH
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3019
Mailing Address - Country:US
Mailing Address - Phone:513-585-5501
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-1000
Practice Address - Country:US
Practice Address - Phone:513-584-2146
Practice Address - Fax:513-584-0431
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-0051-F207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000013583OtherANTHEM
KY64781354Medicaid
OH0377702Medicaid
OH3820017OtherUNITED HEALTHCARE
IN200038970AMedicaid
OH655277OtherAETNA
OH000000013583OtherANTHEM
OHB95464Medicare UPIN