Provider Demographics
NPI:1538168844
Name:PATHROSE, MINI PETERSON (MD)
Entity type:Individual
Prefix:DR
First Name:MINI
Middle Name:PETERSON
Last Name:PATHROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 NW WASHINGTON BLVD
Mailing Address - Street 2:STE. B
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-6386
Mailing Address - Country:US
Mailing Address - Phone:513-867-9000
Mailing Address - Fax:513-785-3675
Practice Address - Street 1:903 NW WASHINGTON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-6386
Practice Address - Country:US
Practice Address - Phone:513-867-9000
Practice Address - Fax:513-785-3675
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080562P207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2357417Medicaid
OHH77629Medicare UPIN
OHP00287935Medicare PIN
OHPA4066745Medicare PIN