Provider Demographics
NPI:1174513667
Name:PUGH, IVAN DARRELL JR (DO)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:DARRELL
Last Name:PUGH
Suffix:JR
Gender:M
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:1995 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-2423
Mailing Address - Country:US
Mailing Address - Phone:330-337-2868
Mailing Address - Fax:330-337-2875
Practice Address - Street 1:2094 E STATE ST
Practice Address - Street 2:SUITE A
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460
Practice Address - Country:US
Practice Address - Phone:330-337-2868
Practice Address - Fax:330-337-2875
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34-00-7483-P208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2890484Medicaid
OH2890484Medicaid