Provider Demographics
NPI:1972580553
Name:EVERETT, DWAINE M
Entity Type:Individual
Prefix:DR
First Name:DWAINE
Middle Name:M
Last Name:EVERETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:OH
Mailing Address - Zip Code:44672-1410
Mailing Address - Country:US
Mailing Address - Phone:330-938-0001
Mailing Address - Fax:330-938-2666
Practice Address - Street 1:115 E OHIO AVE
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:OH
Practice Address - Zip Code:44672-1410
Practice Address - Country:US
Practice Address - Phone:330-938-0001
Practice Address - Fax:330-938-2666
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0960670Medicaid
OH000000140395OtherANTHEM PIN
OH341853890001OtherMMO PIN
OH341853890001OtherMMO PIN
OHU42604Medicare UPIN