Provider Demographics
NPI:1124072418
Name:PODWALL, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PODWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 MARCUS AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042-2057
Mailing Address - Country:US
Mailing Address - Phone:516-466-4700
Mailing Address - Fax:516-466-4810
Practice Address - Street 1:1991 MARCUS AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042-2057
Practice Address - Country:US
Practice Address - Phone:516-466-4700
Practice Address - Fax:516-466-4810
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218672174400000X
NY218672-12084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI51219Medicare UPIN
NY658N01Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER