Provider Demographics
NPI:1376536847
Name:PASSARELLO, WALTER J (DO)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:J
Last Name:PASSARELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6615 CLINGAN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-2159
Mailing Address - Country:US
Mailing Address - Phone:330-757-7888
Mailing Address - Fax:330-757-4912
Practice Address - Street 1:6615 CLINGAN RD
Practice Address - Street 2:SUITE C
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-2159
Practice Address - Country:US
Practice Address - Phone:330-757-7888
Practice Address - Fax:330-757-4912
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000507817OtherANTHEM
OH2101120Medicaid
OH000000139454OtherANTHEM BC/BS
OH2101120Medicaid
OH0863881Medicare ID - Type Unspecified