Healthcare Provider Details

I. General information

NPI: 1497742126
Provider Name (Legal Business Name): GARY T BACKNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 E MARKET ST
WARREN OH
44484-2260
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-9699
  • Fax: 330-856-9935
Mailing address:
  • Phone: 330-856-9699
  • Fax: 330-856-9935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.003970
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: