Provider Demographics
NPI:1265428593
Name:LARDIZABAL, DAVID VELOSO (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:VELOSO
Last Name:LARDIZABAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1853
Mailing Address - Country:US
Mailing Address - Phone:304-388-6441
Mailing Address - Fax:304-388-6445
Practice Address - Street 1:415 MORRIS ST STE 300
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1853
Practice Address - Country:US
Practice Address - Phone:304-388-6441
Practice Address - Fax:304-388-6445
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010848342084N0400X
MO20040325332084N0400X
WV325102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207331000Medicaid
MOP00755509Medicare PIN
MO931874342Medicare PIN
MO152360082Medicare PIN