Provider Demographics
NPI:1073567947
Name:CARDONICK, BRETT DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:DAVID
Last Name:CARDONICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E DURHAM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1821
Mailing Address - Country:US
Mailing Address - Phone:215-242-8632
Mailing Address - Fax:215-242-4226
Practice Address - Street 1:23 E DURHAM ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1821
Practice Address - Country:US
Practice Address - Phone:215-242-8632
Practice Address - Fax:215-242-4226
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC5192111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0237787000OtherPERSONAL CHOICE PROVIDER
PA0237787000OtherPERSONAL CHOICE PROVIDER