Provider Demographics
NPI:1437204625
Name:KINGSBURY, DAVID HOMER (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:HOMER
Last Name:KINGSBURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10145 OSWEGO DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-9332
Mailing Address - Country:US
Mailing Address - Phone:317-823-6000
Mailing Address - Fax:
Practice Address - Street 1:8424 NAAB RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1966
Practice Address - Country:US
Practice Address - Phone:317-872-1197
Practice Address - Fax:317-872-0027
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021190A207N00000X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01375974OtherTRAVELERS
IN4252234OtherAETNA PIN
IN01021190AOtherPHYSICIAN LICENSE
IN2035684001OtherCIGNA
IN000000079811OtherANTHEM PIN
IN061450Medicare PIN
IN01375974OtherTRAVELERS