1821091414 NPI number — DR. DOUGLAS H MUSSER D.O.

Table of content: DR. DOUGLAS H MUSSER D.O. (NPI 1821091414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821091414 NPI number — DR. DOUGLAS H MUSSER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUSSER
Provider First Name:
DOUGLAS
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1821091414
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6470 TIPPECANOE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44406-7036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-758-0577
Provider Business Mailing Address Fax Number:
330-758-0466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1499 BOARDMAN CANFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-4008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-758-0577
Provider Business Practice Location Address Fax Number:
330-533-4587
Provider Enumeration Date:
05/27/2005

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: 207XS0117X , with the licence number:  34.007068 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 34.007068 , 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: 02691 . This is a "LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 341972661 . This is a "TAX ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 02002303A . This is a "LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 2351093 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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