Provider Demographics
NPI:1336111418
Name:WARD, DAVID RUSSELL (AUD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:RUSSELL
Last Name:WARD
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 PROSPECT AVE NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4283
Mailing Address - Country:US
Mailing Address - Phone:505-295-1770
Mailing Address - Fax:
Practice Address - Street 1:5005 PROSPECT AVE NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4283
Practice Address - Country:US
Practice Address - Phone:505-295-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80349231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216695101Medicaid
TXTXB1171146OtherMEDICARE PTAN