=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063746964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID HAUERSTOCK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2009
-----------------------------------------------------
Last Update Date | 08/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 PARK ST
-----------------------------------------------------
City | MALONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12953-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-483-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 172 RIVER RD
-----------------------------------------------------
City | POTSDAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13676-3101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-244-8775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0203X
-----------------------------------------------------
Taxonomy Name | Therapeutic Radiology Physician
-----------------------------------------------------
License Number | 003694
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 271064
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------