Provider Demographics
NPI:1407880198
Name:BAVIS, JAMES ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:BAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 HOLIDAY ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2531
Mailing Address - Country:US
Mailing Address - Phone:330-494-2097
Mailing Address - Fax:330-494-9750
Practice Address - Street 1:4105 HOLIDAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2531
Practice Address - Country:US
Practice Address - Phone:330-494-2097
Practice Address - Fax:330-494-9750
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350824252084N0400X
OH35-08-24252084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00144116OtherRAILROAD MEDICARE
OH2468539Medicaid
I06578Medicare UPIN
OHBA4133241Medicare ID - Type Unspecified