Healthcare Provider Details

I. General information

NPI: 1437254398
Provider Name (Legal Business Name): OTHELLO R REPUYAN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4188 HOLIDAY ST NW
CANTON OH
44718
US

IV. Provider business mailing address

PO BOX 80690
CANTON OH
44708
US

V. Phone/Fax

Practice location:
  • Phone: 330-492-4277
  • Fax: 330-492-6973
Mailing address:
  • Phone: 330-833-5530
  • Fax: 330-833-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: OTHELLO R REPUYAN
Title or Position: PRESIDENT
Credential: MD
Phone: 330-492-4277