Provider Demographics
NPI:1760458202
Name:LONBAKEN, DAVID R (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:LONBAKEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-224-7070
Mailing Address - Fax:605-224-2514
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-224-7070
Practice Address - Fax:605-224-2514
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD131213E00000X
SDSD131213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6800190Medicaid
SDU34007Medicare UPIN
SD103056Medicare PIN
SD2306Medicare ID - Type Unspecified