Provider Demographics
NPI:1316963366
Name:BADER, DONALD L
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:BADER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:
Other - Last Name:BADER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:FT DEFIANCE INDIAN HOSPITAL BOARD
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0589
Mailing Address - Country:US
Mailing Address - Phone:928-729-8600
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504-0589
Practice Address - Country:US
Practice Address - Phone:928-729-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36859207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
930060672OtherRAILROAD
COP00448188OtherRAILROAD MEDICARE PIN
NM000S2505Medicaid
CO01368596Medicaid
930060672OtherRAILROAD
NM000S2505Medicaid
COC804350Medicare PIN