Provider Demographics
NPI:1972508711
Name:MAXWELL, GERALD S (DO)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:S
Last Name:MAXWELL
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 1:5533 MAHONING AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2366
Mailing Address - Country:US
Mailing Address - Phone:330-793-2701
Mailing Address - Fax:330-793-2366
Practice Address - Street 1:5533 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2366
Practice Address - Country:US
Practice Address - Phone:330-793-2701
Practice Address - Fax:330-793-2366
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9661207Q00000X
OH34-006824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2374274Medicaid
FL2744376-00Medicaid
OHF85986Medicare UPIN
OHMA0866564Medicare ID - Type UnspecifiedOHIO MEDICARE
FL2744376-00Medicaid