Healthcare Provider Details

I. General information

NPI: 1326023045
Provider Name (Legal Business Name): DAVID T SUPERDOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 09/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 W 2ND AVE
LITITZ PA
17543-1816
US

IV. Provider business mailing address

562 W 2ND AVE
LITITZ PA
17543-1816
US

V. Phone/Fax

Practice location:
  • Phone: 717-626-2167
  • Fax: 717-626-1915
Mailing address:
  • Phone: 717-626-2167
  • Fax: 717-626-1915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD041940L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier01971402
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS
# 2
Identifier578406
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA HMO
# 3
Identifier615224
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD
# 4
IdentifierE23590
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHEALTH ASSURANCE
# 5
IdentifierP002303
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGATEWAY HEALTH PLAN
# 6
Identifier37716 S1QG
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER HEALTH PLAN
# 7
Identifier5659089
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA NON-HMO
# 8
Identifier0012090930001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: