Provider Demographics
NPI:1619931250
Name:PERDUK, AMBROSE STEVE JR (DC)
Entity type:Individual
Prefix:DR
First Name:AMBROSE
Middle Name:STEVE
Last Name:PERDUK
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WEST SECOND ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622
Mailing Address - Country:US
Mailing Address - Phone:330-343-2621
Mailing Address - Fax:330-343-6006
Practice Address - Street 1:125 WEST SECOND ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622
Practice Address - Country:US
Practice Address - Phone:330-343-2621
Practice Address - Fax:330-343-2621
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1155111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0707668Medicaid
T48326Medicare UPIN
OH0707668Medicaid