Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 35048907 | OH |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 35048907 | OH |
NPI | 1215966890 |
---|---|
Provider Name | Constance D Magoulias |
First Address | Cleveland, OH 44109-1900 |
Second Address | Cleveland, OH 44109-1900 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2006 |
Last Update Date | 27/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0609194 | (05) | OH |
C03061 | (02) | OH |