Healthcare Provider Details

I. General information

NPI: 1679554448
Provider Name (Legal Business Name): DAVID J THALER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ROANOKE BLVD 11AC/1J1
SALEM VA
24153-6404
US

IV. Provider business mailing address

3404 WINDSOR RD SW
ROANOKE VA
24018-2046
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2463
  • Fax: 540-855-3403
Mailing address:
  • Phone: 540-774-4149
  • Fax: 540-855-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0102036861
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: