Provider Demographics
NPI:1538147525
Name:DEWALD, DONALD LEE (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEE
Last Name:DEWALD
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 1:1125 ASPIRA CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4125
Mailing Address - Country:US
Mailing Address - Phone:419-756-2122
Mailing Address - Fax:419-756-5486
Practice Address - Street 1:1125 ASPIRA CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4125
Practice Address - Country:US
Practice Address - Phone:419-756-2122
Practice Address - Fax:419-756-5486
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039490D207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0317473Medicaid
OH4393220001Medicare NSC
OHA84457Medicare UPIN
OH110199600Medicare PIN
OH0423427Medicare PIN
OH0423426Medicare PIN
OH0423428Medicare PIN