Provider Demographics
NPI:1831158906
Name:CERVANTES, DAVID R (MD)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:R
Last Name:CERVANTES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 PARK CENTER CT.
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615
Mailing Address - Country:US
Mailing Address - Phone:419-474-4064
Mailing Address - Fax:419-472-2772
Practice Address - Street 1:5757 PARK CENTER CT.
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615
Practice Address - Country:US
Practice Address - Phone:419-474-4064
Practice Address - Fax:419-472-2772
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0681512085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH137533Medicaid
G01522Medicare UPIN
OH0137533Medicare ID - Type Unspecified
OHCE0780598Medicare PIN
780595Medicare PIN
OHGO1522Medicare UPIN