Provider Demographics
NPI:1871587071
Name:DEPROFIO, DOUGLAS J (PA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:DEPROFIO
Suffix:
Gender:M
Credentials:PA
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Other - Last Name:
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Mailing Address - Street 1:5450 FRANTZ RD
Mailing Address - Street 2:STE 360
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4134
Mailing Address - Country:US
Mailing Address - Phone:614-544-6155
Mailing Address - Fax:614-544-6370
Practice Address - Street 1:931 CHATHAM LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2417
Practice Address - Country:US
Practice Address - Phone:614-533-5500
Practice Address - Fax:614-533-5593
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50-001909363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0068078Medicaid
P71358Medicare UPIN
OHPA19892Medicare PIN