Provider Demographics
NPI:1013469295
Name:DAVID, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:DAVID
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4210
Mailing Address - Country:US
Mailing Address - Phone:718-775-7181
Mailing Address - Fax:
Practice Address - Street 1:1455 WEST AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-7304
Practice Address - Country:US
Practice Address - Phone:718-239-1500
Practice Address - Fax:929-481-4887
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant