MEDICARE: MR. DOUGLAS X DISMUKE I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	171M00000X	OH

General Provider Information

NPI Number	:	1104696608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS X DISMUKE I

Provider Business Mailing Address
First Line	:	3649 REVERE DR
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43612-1032
Country	:	US
Telephone Number	:	815-299-8765
Fax Number	:

Provider Business Practice Location Address
First Line	:	3649 REVERE DR
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43612-1032
Country	:	US
Telephone Number	:	815-299-8765
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2024
Last Update Date	:	01/12/2024

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