Provider Demographics
NPI:1689680621
Name:METZENDORF, DAVID IRA (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:IRA
Last Name:METZENDORF
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 1:135 1ST ST SOUTH
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880
Mailing Address - Country:US
Mailing Address - Phone:863-293-1968
Mailing Address - Fax:863-293-7961
Practice Address - Street 1:135 1ST ST SOUTH
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-293-1968
Practice Address - Fax:863-293-7961
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0001385213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029684800Medicaid
FL593258147OtherTAX ID
FL029684800Medicaid
FL4740460001Medicare NSC
FL878042Medicare ID - Type Unspecified