Provider Demographics
NPI:1710972682
Name:MERRELL, DAVID M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:MERRELL
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 1:6005 MONCLOVA RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1864
Mailing Address - Country:US
Mailing Address - Phone:419-578-7555
Mailing Address - Fax:419-539-6336
Practice Address - Street 1:6005 MONCLOVA RD
Practice Address - Street 2:SUITE 320
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1864
Practice Address - Country:US
Practice Address - Phone:419-578-7555
Practice Address - Fax:419-539-6336
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-3487-M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0399984Medicaid
OH0399984Medicaid
OH0463536Medicare PIN
0463533Medicare PIN
OH0463534Medicare PIN
OHH219210Medicare PIN