=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972599207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID SUESSERMAN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2005
-----------------------------------------------------
Last Update Date | 09/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 CLINTON ST
-----------------------------------------------------
City | HEMPSTEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11550-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-992-8196
-----------------------------------------------------
Fax | 516-992-8198
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 WOODS AVE
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-992-8196
-----------------------------------------------------
Fax | 516-992-8198
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X009397
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------