1710181375 NPI number — DR. DANA LYNN ESHAM MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710181375 NPI number — DR. DANA LYNN ESHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESHAM
Provider First Name:
DANA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710181375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4439 STATE ROUTE 159 STE G70
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHILLICOTHEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45601-7203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4439 STATE ROUTE 159
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHILLICOTHEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45601-8207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-779-4393
Provider Business Practice Location Address Fax Number:
740-779-4399
Provider Enumeration Date:
06/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  BP1-0026317 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: 35.098519 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3851657317 . This is a "MYUTMB 3851657317-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0063380 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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