Provider Demographics
NPI:1326734955
Name:TAIRA, ETHAN TATSUJI (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:TATSUJI
Last Name:TAIRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 S HIGH ST APT 218
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3592
Mailing Address - Country:US
Mailing Address - Phone:630-542-4083
Mailing Address - Fax:
Practice Address - Street 1:2231 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-1115
Practice Address - Country:US
Practice Address - Phone:614-293-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.256493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine