Provider Demographics
NPI:1750443560
Name:SELF, DAVID A (MPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:SELF
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WESTSIDE DR NW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3699
Mailing Address - Country:US
Mailing Address - Phone:423-479-3600
Mailing Address - Fax:423-303-1234
Practice Address - Street 1:2700 WESTSIDE DR NW
Practice Address - Street 2:SUITE 301
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3699
Practice Address - Country:US
Practice Address - Phone:423-479-3600
Practice Address - Fax:423-303-1234
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN5299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4096931OtherBCBS OF TN
3645529Medicare ID - Type Unspecified