Provider Demographics
NPI:1225400021
Name:TATE, DAVANZO JR
Entity type:Individual
Prefix:
First Name:DAVANZO
Middle Name:
Last Name:TATE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6602 HARVEST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-5562
Mailing Address - Country:US
Mailing Address - Phone:330-974-5415
Mailing Address - Fax:
Practice Address - Street 1:6602 HARVEST RIDGE DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-5562
Practice Address - Country:US
Practice Address - Phone:330-974-5415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5004944374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0135706Medicaid