Healthcare Provider Details

I. General information

NPI: 1689644288
Provider Name (Legal Business Name): DAVID MATTHEW HEAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 WEST 5TH AVE
NOME AK
99762-0966
US

IV. Provider business mailing address

PO BOX 966
NOME AK
99762-0966
US

V. Phone/Fax

Practice location:
  • Phone: 907-443-3311
  • Fax: 907-443-3139
Mailing address:
  • Phone: 907-443-3311
  • Fax: 907-443-3139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2369
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: