Provider Demographics
NPI:1073511473
Name:DALVIN, MITCHELL (DPM)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:DALVIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 S RACCOON RD
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4703
Mailing Address - Country:US
Mailing Address - Phone:330-799-3383
Mailing Address - Fax:330-799-3505
Practice Address - Street 1:1749 S RACCOON RD
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-4703
Practice Address - Country:US
Practice Address - Phone:330-799-3383
Practice Address - Fax:330-799-3505
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-09
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36 002104213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0519442Medicaid
OH0519442Medicaid
OHT80545Medicare UPIN