Provider Demographics
NPI:1215062583
Name:WAITS, DAVID EDMOND (MS, ATC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EDMOND
Last Name:WAITS
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MATAWAN RD APT B
Mailing Address - Street 2:
Mailing Address - City:LAURENCE HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2671
Mailing Address - Country:US
Mailing Address - Phone:917-680-3952
Mailing Address - Fax:732-525-5260
Practice Address - Street 1:820 WASHINGTON RD
Practice Address - Street 2:SAYREVILLE WAR MEMORIAL HIGH SCHOOL
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859
Practice Address - Country:US
Practice Address - Phone:732-525-5261
Practice Address - Fax:732-525-5260
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001177002255A2300X
NJ5652882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer