Provider Demographics
NPI:1821183286
Name:JOLLEY, DAVID WAYNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 S 6TH AVE # 2-112B
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:520-792-1450
Mailing Address - Fax:520-629-1897
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:2-112
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:520-629-1706
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT286416-0501213ES0103X, 213E00000X
IDP-203213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT286416-0501OtherUT STATE DOPL
ORDP00432OtherOR STATE MED LIC
IDP-203OtherID STATE BUREAU OCC LIC