Provider Demographics
NPI:1992889851
Name:BREWSTER, DIANA (DO)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BREWSTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4172 HOLIDAY ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2532
Mailing Address - Country:US
Mailing Address - Phone:330-433-9260
Mailing Address - Fax:330-433-9263
Practice Address - Street 1:4172 HOLIDAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2532
Practice Address - Country:US
Practice Address - Phone:330-433-9260
Practice Address - Fax:330-433-9263
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H85206Medicare UPIN
OH4107892Medicare PIN