Healthcare Provider Details

I. General information

NPI: 1285945311
Provider Name (Legal Business Name): JEREMY JAMES MASHBURN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 NORTH RD SE
WARREN OH
44484-2900
US

IV. Provider business mailing address

1552 NORTH RD SE
WARREN OH
44484-2900
US

V. Phone/Fax

Practice location:
  • Phone: 877-469-7476
  • Fax: 330-752-2250
Mailing address:
  • Phone: 877-469-7476
  • Fax: 330-752-2250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS022110
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.011238
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: