Provider Demographics
NPI:1760797120
Name:SONNENBURG, DAVID PHILLIP (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PHILLIP
Last Name:SONNENBURG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E DAY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3408
Mailing Address - Country:US
Mailing Address - Phone:574-271-3939
Mailing Address - Fax:574-271-3941
Practice Address - Street 1:230 E DAY RD STE 100
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3408
Practice Address - Country:US
Practice Address - Phone:574-271-3939
Practice Address - Fax:574-271-3941
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010413152W00000X
IN18003642152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201113290Medicaid
IN2044600006OtherPTAN
INP01171205OtherMEDICARE RAILROAD
INM400075619Medicare PIN