Provider Demographics
NPI:1790853505
Name:PARADIS, DAVID S (LPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:S
Last Name:PARADIS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 DORR ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4467
Mailing Address - Country:US
Mailing Address - Phone:419-539-7701
Mailing Address - Fax:419-539-7718
Practice Address - Street 1:4235 SECOR RD
Practice Address - Street 2:#B3
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4231
Practice Address - Country:US
Practice Address - Phone:419-479-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP001084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH06611556Medicaid
OH344565Medicare ID - Type Unspecified