Healthcare Provider Details

I. General information

NPI: 1104884063
Provider Name (Legal Business Name): DAVID THOMAS POREMBKA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 S CLIFF AVE
SIOUX FALLS SD
57105-1007
US

IV. Provider business mailing address

1325 S CLIFF AVE
SIOUX FALLS SD
57105-1007
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-2460
  • Fax: 605-322-2470
Mailing address:
  • Phone: 605-322-7510
  • Fax: 605-322-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number34-003628
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number9292
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number5101008315
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: