Provider Demographics
NPI:1033156104
Name:DIDUR, DAVID R (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:DIDUR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12521 ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:NORTH JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:44451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 AUSTIN AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-3598
Practice Address - Country:US
Practice Address - Phone:216-837-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005849207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH942460636418OtherCARESOURCE
OH0951493Medicaid
OHP00319997OtherMEDICARE TRAVELERS RR-GA
OHF73406Medicare UPIN
OH942460636418OtherCARESOURCE
OH4311041Medicare PIN
OH0755009Medicare PIN