Healthcare Provider Details

I. General information

NPI: 1669540597
Provider Name (Legal Business Name): BARBARA SHAW CUDDEBACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3170 W CENTRAL AVE
TOLEDO OH
43606
US

IV. Provider business mailing address

1 ELIZABETH PL
DAYTON OH
45417-3445
US

V. Phone/Fax

Practice location:
  • Phone: 567-316-7253
  • Fax:
Mailing address:
  • Phone: 567-316-7253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number061414
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME97311
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35085386
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: