Provider Demographics
NPI:1619956190
Name:FALCONER, DAVID L (OT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:FALCONER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 LINCOLN AVE NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-7398
Mailing Address - Country:US
Mailing Address - Phone:605-881-1100
Mailing Address - Fax:
Practice Address - Street 1:1134 LINCOLN AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-7398
Practice Address - Country:US
Practice Address - Phone:605-881-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0447225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5834950Medicaid
SDS41870Medicare PIN
SDP00116966Medicare PIN