Provider Demographics
NPI:1467874388
Name:DERDIGER, DAVID JOSEPH (LAC, MSOM)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JOSEPH
Last Name:DERDIGER
Suffix:
Gender:M
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 FORESTWAY DR
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4809
Mailing Address - Country:US
Mailing Address - Phone:847-224-0068
Mailing Address - Fax:
Practice Address - Street 1:325 N MILWAUKEE AVE STE D
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3071
Practice Address - Country:US
Practice Address - Phone:847-607-1857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60420428225700000X
IL227013566225700000X
IL198.001395171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist