Provider Demographics
NPI:1689618118
Name:DAVANZO, MARK E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:DAVANZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:477 COOPER RD
Mailing Address - Street 2:SUITE 440
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8053
Mailing Address - Country:US
Mailing Address - Phone:380-898-5561
Mailing Address - Fax:380-898-5563
Practice Address - Street 1:477 COOPER RD
Practice Address - Street 2:SUITE 440
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8053
Practice Address - Country:US
Practice Address - Phone:380-898-5561
Practice Address - Fax:380-898-5563
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2019-03-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35051847208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00880716OtherRR MEDICARE
OH2986050Medicaid
OHDA0566936Medicare PIN
OHAC9380371Medicare PIN