Provider Demographics
NPI:1245231620
Name:DAVE, DEEPAK (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:DAVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 NORTH CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-5802
Mailing Address - Country:US
Mailing Address - Phone:570-459-6666
Mailing Address - Fax:570-459-5386
Practice Address - Street 1:78 NORTH CHURCH STREET
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-5802
Practice Address - Country:US
Practice Address - Phone:570-459-6666
Practice Address - Fax:570-459-5386
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040293L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
180039776OtherRAILROAD MEDICARE
202616OtherEEOICP
34225OtherGEISINGER HEALTH PLAN
073625OtherFIRST PRIORITY HEALTH
111134OtherBLACK LUNG
510552OtherBLUE CROSS / BLUE SHIELD
PA0011614630003Medicaid
510552OtherBLUE CROSS / BLUE SHIELD
202616OtherEEOICP
073625OtherFIRST PRIORITY HEALTH