Provider Demographics
NPI:1053070151
Name:SEYMOUR, DWAYNE EDWARD
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:EDWARD
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2364 ZIRCON ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-1741
Mailing Address - Country:US
Mailing Address - Phone:330-685-2201
Mailing Address - Fax:
Practice Address - Street 1:2364 ZIRCON ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-1741
Practice Address - Country:US
Practice Address - Phone:330-685-2201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7611149251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7611149OtherOHIO DODD