Healthcare Provider Details

I. General information

NPI: 1245231620
Provider Name (Legal Business Name): DEEPAK DAVE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 NORTH CHURCH STREET
HAZLETON PA
18201-5802
US

IV. Provider business mailing address

78 NORTH CHURCH STREET
HAZLETON PA
18201-5802
US

V. Phone/Fax

Practice location:
  • Phone: 570-459-6666
  • Fax: 570-459-5386
Mailing address:
  • Phone: 570-459-6666
  • Fax: 570-459-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD040293L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier180039776
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier202616
Identifier TypeOTHER
Identifier State
Identifier IssuerEEOICP
# 3
Identifier34225
Identifier TypeOTHER
Identifier State
Identifier IssuerGEISINGER HEALTH PLAN
# 4
Identifier073625
Identifier TypeOTHER
Identifier State
Identifier IssuerFIRST PRIORITY HEALTH
# 5
Identifier111134
Identifier TypeOTHER
Identifier State
Identifier IssuerBLACK LUNG
# 6
Identifier510552
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CROSS / BLUE SHIELD
# 7
Identifier0011614630003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: