Healthcare Provider Details

I. General information

NPI: 1609860840
Provider Name (Legal Business Name): DOUGLAS L BLOCKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 EVERHARD RD NW
CANTON OH
44718-2406
US

IV. Provider business mailing address

4575 EVERHARD RD NW
CANTON OH
44718-2406
US

V. Phone/Fax

Practice location:
  • Phone: 330-494-5600
  • Fax: 330-966-1644
Mailing address:
  • Phone: 330-494-5600
  • Fax: 330-966-1644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35037737
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: