Provider Demographics
NPI:1215525340
Name:MYTROFANOVA, OLGA
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:MYTROFANOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23900 COMMERCE PARK
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5822
Mailing Address - Country:US
Mailing Address - Phone:440-753-6030
Mailing Address - Fax:440-232-3801
Practice Address - Street 1:23900 COMMERCE PARK
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5822
Practice Address - Country:US
Practice Address - Phone:440-753-6030
Practice Address - Fax:440-232-3801
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty