Provider Demographics
NPI:1609990852
Name:POORTINGA, GERARD P (DC)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:P
Last Name:POORTINGA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1709
Mailing Address - Country:US
Mailing Address - Phone:937-767-1115
Mailing Address - Fax:937-767-9997
Practice Address - Street 1:525 DAYTON ST
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1709
Practice Address - Country:US
Practice Address - Phone:937-767-1115
Practice Address - Fax:937-767-9997
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH764111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0450211Medicaid
OH0450211Medicaid
OHT47074Medicare UPIN