Provider Demographics
NPI:1508421793
Name:TAGUE, DAVID MICHAEL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:TAGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 N MAYFAIR RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1404
Mailing Address - Country:US
Mailing Address - Phone:474-475-5809
Mailing Address - Fax:
Practice Address - Street 1:2505 N MAYFAIR RD STE 104
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1404
Practice Address - Country:US
Practice Address - Phone:474-475-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS001006237700000X
WI1587-60237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist