Provider Demographics
NPI:1992759377
Name:MUTASIM, DIYA F (M D)
Entity type:Individual
Prefix:
First Name:DIYA
Middle Name:F
Last Name:MUTASIM
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-4231
Mailing Address - Country:US
Mailing Address - Phone:513-475-7630
Mailing Address - Fax:513-475-7636
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-7630
Practice Address - Fax:513-475-7636
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.059745207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH070004743OtherRR MEDICARE
OH0781882Medicaid
IN200038080AMedicaid
KY64869787Medicaid
OH070004743OtherMEDICARE RR
OHMU0665005Medicare PIN
OH0781882Medicaid
E68853Medicare UPIN
OHMU0846953Medicare PIN
OHMU0665002Medicare ID - Type Unspecified
IN200038080AMedicaid