Provider Demographics
NPI:1922162320
Name:DUVENDACK, DAVID TIMOTHY (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TIMOTHY
Last Name:DUVENDACK
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:PO BOX 351627
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43635-1627
Mailing Address - Country:US
Mailing Address - Phone:419-425-9273
Mailing Address - Fax:419-423-7124
Practice Address - Street 1:4445 WOODMONT RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-3320
Practice Address - Country:US
Practice Address - Phone:419-346-3216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH5026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDU4023733Medicare ID - Type Unspecified
OHU80636Medicare UPIN