Provider Demographics
NPI:1538153689
Name:POWELL, DAVID DEREK (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DEREK
Last Name:POWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805
Mailing Address - Country:US
Mailing Address - Phone:419-221-2273
Mailing Address - Fax:419-227-3737
Practice Address - Street 1:2740 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805
Practice Address - Country:US
Practice Address - Phone:419-221-2273
Practice Address - Fax:419-227-3737
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006220P207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0179542Medicaid
OH4065883Medicare ID - Type Unspecified
OH0179542Medicaid
OH734871Medicare PIN