Provider Demographics
NPI:1275099020
Name:MEDANSKY, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MEDANSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 W SHIFTING SANDS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2623
Mailing Address - Country:US
Mailing Address - Phone:602-721-5218
Mailing Address - Fax:
Practice Address - Street 1:11980 W SHIFTING SANDS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2623
Practice Address - Country:US
Practice Address - Phone:602-721-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
2083B002XOtherTAXONOMY