Provider Demographics
NPI:1174582332
Name:HUMPHREY, JOHN B JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:HUMPHREY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6046 WHIPPLE AVENUE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720
Mailing Address - Country:US
Mailing Address - Phone:330-433-1400
Mailing Address - Fax:330-305-5047
Practice Address - Street 1:6046 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720
Practice Address - Country:US
Practice Address - Phone:330-433-1200
Practice Address - Fax:330-305-5047
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039433207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0316116Medicaid
OHHU7147411Medicare PIN
OH0316116Medicaid
OHHU0425051Medicare PIN