Provider Demographics
NPI:1508831090
Name:POULTER, DAVID CLARK (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CLARK
Last Name:POULTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1502
Mailing Address - Country:US
Mailing Address - Phone:763-689-2462
Mailing Address - Fax:763-689-1688
Practice Address - Street 1:137 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008
Practice Address - Country:US
Practice Address - Phone:763-689-2462
Practice Address - Fax:763-689-1688
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57082251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic