Provider Demographics
NPI:1275589699
Name:POOR, DAVID DEWILE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DEWILE
Last Name:POOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5126 W DAYBREAK PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5994
Mailing Address - Country:US
Mailing Address - Phone:801-213-4500
Mailing Address - Fax:801-213-5368
Practice Address - Street 1:2133 S STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-9781
Practice Address - Country:US
Practice Address - Phone:812-232-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5684661-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1982871828Medicaid
UT1982871828Medicaid
UT000066661Medicare PIN