Basic Information
| Provider Information | |||||||||
| NPI: | 1962434373 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | UDSTUEN | ||||||||
| FirstName: | GAVIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 CENTRAL CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453107 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | DEPT. OF RADIOLOGY | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452671000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135847544 | ||||||||
| FaxNumber: | 5135849100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 02/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35-07-1170 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000228669 | 01 | OH | ANTHEM | OTHER | 300134540 | 01 | OH | RAILROAD MEDICARE | OTHER | 1805944000 | 05 | WV | MEDICAID | 1603249 | 01 | OH | UNITED HEALTHCARE | OTHER | 2214857 | 05 | OH | MEDICAID | 200411300A | 05 | IN | MEDICAID | 2903618 | 01 | OH | AETNA | OTHER | 64028558 | 05 | KY | MEDICAID |