Provider Demographics
NPI:1558360545
Name:TALBUT, DORRENCE CONEY (MD)
Entity Type:Individual
Prefix:
First Name:DORRENCE
Middle Name:CONEY
Last Name:TALBUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:D.
Other - Middle Name:C
Other - Last Name:TALBUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5757 MONCLOVA RD
Mailing Address - Street 2:#2
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-893-7607
Mailing Address - Fax:419-893-7608
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:#2
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-7607
Practice Address - Fax:419-893-7608
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3502 0459T208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI335611Medicaid
OH448094OtherWORKERS COMP
OH47069Medicaid
OH47069Medicaid