Provider Demographics
NPI:1437151644
Name:GERECKE, DAVID MARK (CPO, FAAOP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARK
Last Name:GERECKE
Suffix:
Gender:M
Credentials:CPO, FAAOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64371
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98464-0371
Mailing Address - Country:US
Mailing Address - Phone:206-450-6769
Mailing Address - Fax:253-753-1825
Practice Address - Street 1:3614 72ND AVENUE CT W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4407
Practice Address - Country:US
Practice Address - Phone:206-450-7669
Practice Address - Fax:253-753-1825
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1270222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
51-0672413OtherTAX ID NUMBER