Provider Demographics
NPI:1619129442
Name:DAVID, DOUGLAS R (DPM)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:DAVID
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-2067
Mailing Address - Country:US
Mailing Address - Phone:201-262-3915
Mailing Address - Fax:
Practice Address - Street 1:55 EAST 124TH STREET
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10035-1518
Practice Address - Country:US
Practice Address - Phone:212-410-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003074213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00692993Medicaid