Provider Demographics
NPI:1205396843
Name:AUDU, MARYAM (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:AUDU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 5TH ST NE STE 16
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-3017
Mailing Address - Country:US
Mailing Address - Phone:330-615-3283
Mailing Address - Fax:330-615-3284
Practice Address - Street 1:201 5TH ST NE STE 16
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-3017
Practice Address - Country:US
Practice Address - Phone:330-375-3315
Practice Address - Fax:330-615-3284
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.141587207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program