Provider Demographics
NPI:1174206940
Name:DEOLDEN, DAVID GERARD II (LMT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GERARD
Last Name:DEOLDEN
Suffix:II
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7868 PECK ROAD
Mailing Address - Street 2:
Mailing Address - City:KIRKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13082
Mailing Address - Country:US
Mailing Address - Phone:315-400-7909
Mailing Address - Fax:
Practice Address - Street 1:7868 PECK ROAD
Practice Address - Street 2:
Practice Address - City:KIRKVILLE
Practice Address - State:NY
Practice Address - Zip Code:13082
Practice Address - Country:US
Practice Address - Phone:315-400-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist