1275539918 NPI number — DAVID K ISRAEL D.O.

Table of content: DAVID K ISRAEL D.O. (NPI 1275539918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275539918 NPI number — DAVID K ISRAEL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISRAEL
Provider First Name:
DAVID
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1275539918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHRISTOPHER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62822-0155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-724-2401
Provider Business Mailing Address Fax Number:
618-724-4628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 NW 11TH ST
Provider Second Line Business Practice Location Address:
# 209
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62837-1218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-842-4470
Provider Business Practice Location Address Fax Number:
618-842-3437
Provider Enumeration Date:
06/27/2005

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: 208000000X , with the licence number:  036104743 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036104743 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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