Healthcare Provider Details

I. General information

NPI: 1093792954
Provider Name (Legal Business Name): DAVID BRENT WIRTH M.A., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR 88 MDG SGOS/SGCXL
WRIGHT PATTERSON AFB OH
45433-5546
US

IV. Provider business mailing address

2424 OAKBROOK BLVD
BEAVERCREEK OH
45434-7097
US

V. Phone/Fax

Practice location:
  • Phone: 937-787-9280
  • Fax:
Mailing address:
  • Phone: 937-255-5227
  • Fax: 937-656-7617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number28
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: