1124095443 NPI number — DAVID B PEISNER MD

Table of content: DAVID B PEISNER MD (NPI 1124095443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124095443 NPI number — DAVID B PEISNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEISNER
Provider First Name:
DAVID
Provider Middle Name:
B
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:
1124095443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
869 BEAVER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBOIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-371-6501
Provider Business Mailing Address Fax Number:
814-371-6504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
869 BEAVER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBOIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-371-6501
Provider Business Practice Location Address Fax Number:
814-371-6504
Provider Enumeration Date:
03/06/2006

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: 207VM0101X , with the licence number:  MD433961 , 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: MD433961 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1021144330001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102114433 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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