Provider Demographics
NPI:1396797510
Name:NEIDHARDT, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:NEIDHARDT
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 1:915 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2768
Mailing Address - Country:US
Mailing Address - Phone:419-229-4747
Mailing Address - Fax:419-224-3348
Practice Address - Street 1:915 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2768
Practice Address - Country:US
Practice Address - Phone:419-229-4747
Practice Address - Fax:419-224-3348
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0681785Medicaid
OH010024599OtherMEDICARE RR
OHP00072000OtherMEDICARE RAILROAD
OH000000317842OtherANTHEM/BCBS
OH000000317842OtherANTHEM/BCBS
OH0627686Medicare PIN
OHD97905Medicare UPIN