Provider Demographics
NPI:1386623395
Name:PROSSER, DAVID J (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:PROSSER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8918 RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-2807
Mailing Address - Country:US
Mailing Address - Phone:605-347-2549
Mailing Address - Fax:
Practice Address - Street 1:910 HARMON ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-2556
Practice Address - Country:US
Practice Address - Phone:605-347-2666
Practice Address - Fax:605-347-5823
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9202612Medicaid
SDU21957Medicare UPIN
SD9202612Medicaid