Healthcare Provider Details

I. General information

NPI: 1568452886
Provider Name (Legal Business Name): DAVID JACKSON PATEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 BELMONT AVE
BRATTLEBORO VT
05301-7110
US

IV. Provider business mailing address

169 TOLMAN POND RD
NELSON NH
03457-5521
US

V. Phone/Fax

Practice location:
  • Phone: 802-257-8363
  • Fax: 802-258-4903
Mailing address:
  • Phone: 603-847-9745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number042-0007486
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: