1194771824 NPI number — DAVID PASTOOR MD

Table of content: DAVID PASTOOR MD (NPI 1194771824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194771824 NPI number — DAVID PASTOOR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PASTOOR
Provider First Name:
DAVID
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:
1194771824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5511 W US HIGHWAY 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUDINGTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49431-2455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-843-1553
Provider Business Mailing Address Fax Number:
231-845-5515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4478 DOWLING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTAGUE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49437-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-894-4531
Provider Business Practice Location Address Fax Number:
231-894-8158
Provider Enumeration Date:
05/25/2006

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: 207Q00000X , with the licence number:  4301053688 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DP053688 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00727292 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5409154 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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