Provider Demographics
NPI:1639191513
Name:DUBORD, DAVID ROGER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROGER
Last Name:DUBORD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6815W CAPITOL DR 314
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2056
Mailing Address - Country:US
Mailing Address - Phone:414-771-8110
Mailing Address - Fax:414-771-7123
Practice Address - Street 1:6001 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1527
Practice Address - Country:US
Practice Address - Phone:414-771-8110
Practice Address - Fax:414-771-7123
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2488-057103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39768400Medicaid