Provider Demographics
NPI:1811601040
Name:LIDGE, DONTAY L
Entity type:Individual
Prefix:
First Name:DONTAY
Middle Name:L
Last Name:LIDGE
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 1:932 KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44306-2816
Mailing Address - Country:US
Mailing Address - Phone:330-962-9944
Mailing Address - Fax:
Practice Address - Street 1:932 KELLY AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44306-2816
Practice Address - Country:US
Practice Address - Phone:330-510-7542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker