Provider Demographics
NPI:1881097087
Name:DIANA BREWSTER, D.O., LLC
Entity type:Organization
Organization Name:DIANA BREWSTER, D.O., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-433-9260
Mailing Address - Street 1:4124 FULTON DR NW
Mailing Address - Street 2:STE 101
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2852
Mailing Address - Country:US
Mailing Address - Phone:330-433-9260
Mailing Address - Fax:330-433-9263
Practice Address - Street 1:4124 FULTON DR NW
Practice Address - Street 2:STE 101
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2852
Practice Address - Country:US
Practice Address - Phone:330-433-9260
Practice Address - Fax:330-433-9263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2399855Medicaid