Provider Demographics
NPI:1306855069
Name:NIEDEREE, DAVID WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:NIEDEREE
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 1:1101 N ROCK RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3735
Mailing Address - Country:US
Mailing Address - Phone:316-788-6963
Mailing Address - Fax:316-788-5373
Practice Address - Street 1:1101 N ROCK RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3735
Practice Address - Country:US
Practice Address - Phone:316-788-6963
Practice Address - Fax:316-788-5373
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-20172207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS057436OtherBC/BS
KS057436OtherBC/BS
KS057436Medicare ID - Type Unspecified