Healthcare Provider Details

I. General information

NPI: 1154301893
Provider Name (Legal Business Name): GARY JOSEPH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 EASTLAND AVE SE
WARREN OH
44484-4503
US

IV. Provider business mailing address

5700 DARROW RD SUITE 106
HUDSON OH
44236-5021
US

V. Phone/Fax

Practice location:
  • Phone: 330-841-4000
  • Fax: 330-656-5901
Mailing address:
  • Phone: 330-656-5911
  • Fax: 330-656-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34-006110 J
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: