Provider Demographics
NPI:1548269756
Name:UTLAK, DAVID J (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:UTLAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4825 HIGBEE AVE NW STE 102
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2567
Mailing Address - Country:US
Mailing Address - Phone:330-492-2102
Mailing Address - Fax:330-492-1025
Practice Address - Street 1:4825 HIGBEE AVE NW STE 102
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2567
Practice Address - Country:US
Practice Address - Phone:330-492-2102
Practice Address - Fax:330-492-1025
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 -043878207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0534952Medicaid
OHUT0489593Medicare ID - Type Unspecified
OHA79878Medicare UPIN