Provider Demographics
NPI:1316942063
Name:LAURICELLA, CHRISTOPHER J (DO)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:LAURICELLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:9000 N MAIN ST STE G-35
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415
Practice Address - Country:US
Practice Address - Phone:937-836-4361
Practice Address - Fax:937-836-1140
Is Sole Proprietor?:No
Enumeration Date:2005-06-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008436L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2552134Medicaid
OH4159164Medicare PIN
OH2552134Medicaid