Provider Demographics
NPI:1063410611
Name:BERTIN, ANTHONY PATRICK (DO)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:PATRICK
Last Name:BERTIN
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 1:4976 TUSCARAWAS ST W
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-5057
Mailing Address - Country:US
Mailing Address - Phone:330-479-0114
Mailing Address - Fax:330-479-0208
Practice Address - Street 1:4976 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-5057
Practice Address - Country:US
Practice Address - Phone:330-479-0114
Practice Address - Fax:330-479-0208
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-003103208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0504592Medicaid
OHBE0522472Medicare ID - Type Unspecified
A80494Medicare UPIN