Provider Demographics
NPI:1952497836
Name:GARRIOTT, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:GARRIOTT
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 1:671 EDGEWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44403-9720
Mailing Address - Country:US
Mailing Address - Phone:330-448-6351
Mailing Address - Fax:330-448-4439
Practice Address - Street 1:671 EDGEWOOD DR SE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:OH
Practice Address - Zip Code:44403-9720
Practice Address - Country:US
Practice Address - Phone:330-448-6351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034735A2085R0202X
OH350354262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000527824OtherANTHEM
OHP00412459OtherRAILROAD MEDICARE
OH0304914OtherBCMH
OH000000225723OtherUNISON
OH7541366OtherAETNA
OH0891174Medicaid
OH421783OtherWELLCARE
OH751140OtherBUCKEYE
OH0891174Medicaid
OH0304914OtherBCMH
OHGA4148752Medicare PIN