Provider Demographics
NPI:1871502419
Name:CRYDERMAN, DAVID JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:CRYDERMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3801
Mailing Address - Country:US
Mailing Address - Phone:219-763-7970
Mailing Address - Fax:219-762-5338
Practice Address - Street 1:6325 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3801
Practice Address - Country:US
Practice Address - Phone:219-763-7970
Practice Address - Fax:219-762-5338
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001744111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN183130Medicare ID - Type Unspecified
U51297Medicare UPIN