Provider Demographics
NPI:1467874388
Name:DERDIGER, DAVID JOSEPH (LAC, MSOM)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JOSEPH
Last Name:DERDIGER
Suffix:
Gender:M
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 DEERFIELD RD STE E
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3750
Mailing Address - Country:US
Mailing Address - Phone:224-833-8033
Mailing Address - Fax:
Practice Address - Street 1:1855 DEERFIELD RD STE E
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3750
Practice Address - Country:US
Practice Address - Phone:224-833-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-12
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001395171100000X, 171100000X
IL227013566225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist