Provider Demographics
NPI:1770585655
Name:DEXTER, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DEXTER
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 1:367 S GULPH RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:941-254-6767
Mailing Address - Fax:941-213-6991
Practice Address - Street 1:8340 LAKEWOOD RANCH BLVD STE 290
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-5182
Practice Address - Country:US
Practice Address - Phone:941-254-6767
Practice Address - Fax:941-213-6991
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070484L208600000X
FLME147949208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNL667OtherPTAN
FL109521700Medicaid
NY02079550OtherNY MEDICAL ASSISTANCE
PA847165OtherBLUE SHIELD
PA847165OtherBLUE SHIELD
PA2611530OtherAETNA
PA0017975110008Medicaid
WV1068876OtherW. VIRGINIA WORKERS COMP
PA020050068OtherRR MEDICARE
PA106531OtherUNISON
PA212526OtherUPMC
PA2611530OtherAETNA
PA0017975110008Medicaid