Healthcare Provider Details

I. General information

NPI: 1053465377
Provider Name (Legal Business Name): DAVID W GNEWIKOW PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 PLEASANT GROVE PL STE C
MOUNT JULIET TN
37122-1501
US

IV. Provider business mailing address

404 LAUREL HILLS DR
MOUNT JULIET TN
37122-8406
US

V. Phone/Fax

Practice location:
  • Phone: 615-406-0500
  • Fax:
Mailing address:
  • Phone: 615-758-4901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1262
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: