Provider Demographics
NPI:1760489322
Name:BOTH, JOHN CALVIN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CALVIN
Last Name:BOTH
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 1:5757 MONCLOVA RD
Mailing Address - Street 2:STE 26
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-893-5557
Mailing Address - Fax:419-893-5199
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:STE 26
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-5557
Practice Address - Fax:419-893-5199
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005250B207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0877154Medicaid
F33488Medicare UPIN
OH0877154Medicaid