Basic Information
| Provider Information | |||||||||
| NPI: | 1699731877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DEAR | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4151 HOLIDAY ST NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304928001 | ||||||||
| FaxNumber: | 3304922080 | ||||||||
| Practice Location | |||||||||
| Address1: | 4151 HOLIDAY ST NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304928001 | ||||||||
| FaxNumber: | 3304922080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 12/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35075799O | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2121313 | 05 | OH | MEDICAID |