Provider Demographics
NPI:1154340875
Name:PHELPS, DAVID MILLARD (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MILLARD
Last Name:PHELPS
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 1:286 STAGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:NY
Mailing Address - Zip Code:12019-2619
Mailing Address - Country:US
Mailing Address - Phone:518-399-2101
Mailing Address - Fax:518-399-2130
Practice Address - Street 1:286 STAGE RD
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:NY
Practice Address - Zip Code:12019-2619
Practice Address - Country:US
Practice Address - Phone:518-399-2101
Practice Address - Fax:518-399-2130
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY070516000112OtherFIDELIS
NY10001608OtherCDPHP
NY11111OtherMVP
NY47349OtherGHI/HMO
NY28N101OtherEMPIRE BC
NY000401067002OtherBSNENY
NY00715540Medicaid
NY200270OtherSENIOR WHOLE HEALTH
NY5546684OtherAETNA
NY5546684OtherAETNA
NY56827FMedicare ID - Type UnspecifiedUPSTATE MEDICARE