Provider Demographics
NPI:1174081095
Name:TATUM, JOHN BENJAMIN DAVID (DD PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BENJAMIN DAVID
Last Name:TATUM
Suffix:
Gender:M
Credentials:DD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 DAWSON AVENUE
Mailing Address - Street 2:BACK DOOR @ TOP OF W/C RAMP
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3201
Mailing Address - Country:US
Mailing Address - Phone:419-524-8337
Mailing Address - Fax:
Practice Address - Street 1:99 DAWSON AVENUE
Practice Address - Street 2:BACK DOOR @ TOP OF W/C RAMP
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3201
Practice Address - Country:US
Practice Address - Phone:419-524-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-10
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No376J00000XNursing Service Related ProvidersHomemaker