Provider Demographics
NPI:1871589887
Name:MANTOR, GINA K (MD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:K
Last Name:MANTOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:K
Other - Last Name:MAYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:285 W SCHROCK RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2874
Mailing Address - Country:US
Mailing Address - Phone:614-818-9550
Mailing Address - Fax:614-818-9556
Practice Address - Street 1:285 W SCHROCK RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2874
Practice Address - Country:US
Practice Address - Phone:614-818-9550
Practice Address - Fax:614-818-9556
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-0913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2419476Medicaid
OH4111602Medicare PIN
OH2419476Medicaid