Provider Demographics
NPI:1023002938
Name:CREDICO, JOHN DOMINIC (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOMINIC
Last Name:CREDICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 BAY PARK DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-4921
Mailing Address - Country:US
Mailing Address - Phone:419-690-7611
Mailing Address - Fax:419-691-1511
Practice Address - Street 1:2751 BAY PARK DR
Practice Address - Street 2:SUITE 304
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4921
Practice Address - Country:US
Practice Address - Phone:419-690-7611
Practice Address - Fax:419-691-1511
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053584207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0601405Medicaid
OH0601405Medicaid
SP03121Medicare PIN