1215921770 NPI number — DR. MARC FREDERIQUE DAVID M.D.

Table of content: DR. MARC FREDERIQUE DAVID M.D. (NPI 1215921770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215921770 NPI number — DR. MARC FREDERIQUE DAVID M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVID
Provider First Name:
MARC
Provider Middle Name:
FREDERIQUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVID
Provider Other First Name:
ANDREA CARLO MARC
Provider Other Middle Name:
FREDERIQUE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1215921770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23995
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31403-3995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-354-4239
Provider Business Mailing Address Fax Number:
912-200-3922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 E 66TH ST
Provider Second Line Business Practice Location Address:
I CARE FAMILY MEDICINE CLINIC
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405-4507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-354-4239
Provider Business Practice Location Address Fax Number:
912-200-3922
Provider Enumeration Date:
09/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  26091 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003121635A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".