Provider Demographics
NPI:1679646251
Name:NESSELROADE, DAVID W
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:NESSELROADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15051 SHELL POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-1639
Mailing Address - Country:US
Mailing Address - Phone:239-454-2146
Mailing Address - Fax:239-454-2111
Practice Address - Street 1:15051 SHELL POINT BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-1639
Practice Address - Country:US
Practice Address - Phone:239-454-2146
Practice Address - Fax:239-454-2111
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA72693Medicare UPIN
35431ZMedicare PIN