Healthcare Provider Details

I. General information

NPI: 1306834809
Provider Name (Legal Business Name): DAVID JACOB HEATH DO, MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 8TH ST NE
MASSILLON OH
44646-8503
US

IV. Provider business mailing address

875 8TH ST NE
MASSILLON OH
44646-8503
US

V. Phone/Fax

Practice location:
  • Phone: 330-832-8761
  • Fax:
Mailing address:
  • Phone: 330-832-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 0000000793
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.010641
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: