Provider Demographics
NPI:1104696608
Name:DISMUKE, DOUGLAS X I
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:X
Last Name:DISMUKE
Suffix:I
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 1:3649 REVERE DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1032
Mailing Address - Country:US
Mailing Address - Phone:815-299-8765
Mailing Address - Fax:
Practice Address - Street 1:3649 REVERE DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1032
Practice Address - Country:US
Practice Address - Phone:815-299-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator