Provider Demographics
NPI:1508869702
Name:DEWALT, JOHN DUFFY (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DUFFY
Last Name:DEWALT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138
Mailing Address - Country:US
Mailing Address - Phone:740-385-1881
Mailing Address - Fax:740-385-1875
Practice Address - Street 1:144 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138
Practice Address - Country:US
Practice Address - Phone:740-385-1881
Practice Address - Fax:740-385-1875
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002686D208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1269034OtherBWC PROVIDER NUMBER
OHCD3781OtherMEDICARE RAILROAD
OH0365073Medicaid
OHB77505Medicare UPIN
OHP00163916Medicare Oscar/Certification
OH0451527Medicare PIN