Healthcare Provider Details

I. General information

NPI: 1023002938
Provider Name (Legal Business Name): JOHN DOMINIC CREDICO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 BAY PARK DR SUITE 304
OREGON OH
43616-4921
US

IV. Provider business mailing address

2751 BAY PARK DR SUITE 304
OREGON OH
43616-4921
US

V. Phone/Fax

Practice location:
  • Phone: 419-690-7611
  • Fax: 419-691-1511
Mailing address:
  • Phone: 419-690-7611
  • Fax: 419-691-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number35053584
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: