MEDICARE: DR. JOHN DUFFY DEWALT D.O.

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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	34002686D	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CD3781	OTHER	OH	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1269034	OTHER	OH	BWC PROVIDER NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508869702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN DUFFY DEWALT D.O.

Provider Business Mailing Address
First Line	:	144 E MAIN ST
Second Line	:
City	:	LOGAN
State	:	OH
Zip	:	43138
Country	:	US
Telephone Number	:	740-385-1881
Fax Number	:	740-385-1875

Provider Business Practice Location Address
First Line	:	144 EAST MAIN STREET
Second Line	:
City	:	LOGAN
State	:	OH
Zip	:	43138
Country	:	US
Telephone Number	:	740-385-1881
Fax Number	:	740-385-1875

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	01/13/2016

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Directions to “ DR. JOHN DUFFY DEWALT D.O.” Practice Location

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