Provider Demographics
NPI:1750368825
Name:DEMIDOVICH, JAMES CHARLES (DO)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:CHARLES
Last Name:DEMIDOVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:6674 TIPPECANOE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9149
Mailing Address - Country:US
Mailing Address - Phone:330-533-8490
Mailing Address - Fax:330-533-8783
Practice Address - Street 1:6674 TIPPECANOE RD STE 1
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9149
Practice Address - Country:US
Practice Address - Phone:330-533-8490
Practice Address - Fax:330-533-8783
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34-00-3113D208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080053951OtherRAILROAD MEDICARE
OH0449394Medicaid
OH0503567Medicare PIN
OH0449394Medicaid