Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 35.141481 | OH |
N | 2080P0204X | Pediatric Emergency Doctor | 35.141481 | OH |
NPI | 1154827061 |
---|---|
Provider Name | Gracia De Jong |
First Address | Columbus, OH 43205-2664 |
Second Address | Columbus, OH 43205-2664 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/04/2018 |
Last Update Date | 10/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0435440 | (05) | OH |
H771400 | CGS MEDICARE (01) | OH |