1245231620 NPI number — DEEPAK DAVE MD

Table of content: DEEPAK DAVE MD (NPI 1245231620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245231620 NPI number — DEEPAK DAVE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVE
Provider First Name:
DEEPAK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245231620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
78 NORTH CHURCH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZLETON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18201-5802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-459-6666
Provider Business Mailing Address Fax Number:
570-459-5386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78 NORTH CHURCH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201-5802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-459-6666
Provider Business Practice Location Address Fax Number:
570-459-5386
Provider Enumeration Date:
08/09/2005

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: 207W00000X , with the licence number:  MD040293L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180039776 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 202616 . This is a "EEOICP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 34225 . This is a "GEISINGER HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 073625 . This is a "FIRST PRIORITY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111134 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 510552 . This is a "BLUE CROSS / BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0011614630003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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