Provider Demographics
NPI:1508053158
Name:DANTONIO, DEIRDRE LEIGH (DC)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:LEIGH
Last Name:DANTONIO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5003 GRIFFIN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-9586
Mailing Address - Country:US
Mailing Address - Phone:541-608-0488
Mailing Address - Fax:
Practice Address - Street 1:10 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7445
Practice Address - Country:US
Practice Address - Phone:541-608-0169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR282576111N00000X
MT782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT67005Medicare UPIN
OR134201Medicare PIN