Provider Demographics
NPI:1669961124
Name:EBERHARDT, DUFFY DAVID
Entity type:Individual
Prefix:
First Name:DUFFY
Middle Name:DAVID
Last Name:EBERHARDT
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:N7936 WOODY LN
Mailing Address - Street 2:
Mailing Address - City:IXONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53036-9479
Mailing Address - Country:US
Mailing Address - Phone:262-510-8130
Mailing Address - Fax:
Practice Address - Street 1:N7936 WOODY LN
Practice Address - Street 2:
Practice Address - City:IXONIA
Practice Address - State:WI
Practice Address - Zip Code:53036-9479
Practice Address - Country:US
Practice Address - Phone:262-510-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic