Provider Demographics
NPI:1922235340
Name:NORTHCUTT, DAVID R (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:NORTHCUTT
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 1:1791 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-5029
Mailing Address - Country:US
Mailing Address - Phone:812-333-4422
Mailing Address - Fax:812-333-6698
Practice Address - Street 1:1791 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-5029
Practice Address - Country:US
Practice Address - Phone:812-333-4422
Practice Address - Fax:812-333-6698
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1899213ES0103X
IN07001351213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300042601Medicaid