Provider Demographics
NPI:1629101928
Name:HADLOCK, DAVID REED (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:REED
Last Name:HADLOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 C SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4563
Mailing Address - Country:US
Mailing Address - Phone:208-735-0000
Mailing Address - Fax:208-734-1717
Practice Address - Street 1:496 C SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4563
Practice Address - Country:US
Practice Address - Phone:208-735-0000
Practice Address - Fax:208-734-1717
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-163207QA0401X, 207VE0102X
ID0-163208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004312000Medicaid
ID1301481Medicare ID - Type Unspecified
ID004312000Medicaid