Provider Demographics
NPI:1124110275
Name:CHAVEZ, DAVID R (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:CHAVEZ
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:ONE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-653-9882
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-653-9882
Practice Address - Fax:603-653-0908
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8217208800000X
WY6858A208800000X
NH15955208800000X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0053278Medicaid
WY118564100Medicaid
MT000084347Medicare PIN
WY20098Medicare PIN
G17760Medicare UPIN