1841269057 NPI number — JOHN M. DUCHAK III MD

Table of content: JOHN M. DUCHAK III MD (NPI 1841269057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841269057 NPI number — JOHN M. DUCHAK III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUCHAK
Provider First Name:
JOHN
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
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:
1841269057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 MIAMISBURG CENTERVILLE RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMISBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45342-7615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-866-0637
Provider Business Mailing Address Fax Number:
937-866-6713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1126 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45409-2687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-223-3053
Provider Business Practice Location Address Fax Number:
937-463-1765
Provider Enumeration Date:
03/17/2006

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: 207RC0000X , with the licence number:  35.064642 , 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: 110077875 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0952518 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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