Provider Demographics
NPI:1831225630
Name:ANDERSON, DAVID J (ATC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1921
Mailing Address - Country:US
Mailing Address - Phone:860-225-5419
Mailing Address - Fax:
Practice Address - Street 1:35 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1921
Practice Address - Country:US
Practice Address - Phone:860-225-5419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT22OtherATHLETIC TRAINER