Provider Demographics
NPI:1215939848
Name:IMM, JOHN P (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:IMM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 BIRCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2967
Mailing Address - Country:US
Mailing Address - Phone:419-334-8943
Mailing Address - Fax:419-334-8619
Practice Address - Street 1:5700 MONROE ST UNIT 111
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2779
Practice Address - Country:US
Practice Address - Phone:567-585-0005
Practice Address - Fax:567-585-0007
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064477207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000277395OtherAZNTHEM
OH04213OtherPARAMOUNT
OH0992010Medicaid
OH080191952OtherRRMC
OH15-70029OtherUHC
OH4553666OtherAETNA
OH04213OtherPARAMOUNT
OH0992010Medicaid