Provider Demographics
NPI:1770656068
Name:ADDIS, DAVID JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:ADDIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 FARNSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505
Mailing Address - Country:US
Mailing Address - Phone:609-298-1823
Mailing Address - Fax:609-298-9363
Practice Address - Street 1:334 FARNSWORTH AVE
Practice Address - Street 2:
Practice Address - City:BORDENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08505
Practice Address - Country:US
Practice Address - Phone:609-298-1823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02546000208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AD064468Medicare ID - Type Unspecified
C52886Medicare UPIN