Provider Demographics
NPI:1427156868
Name:CHISHOLM, MD, DAVID REGINALD (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:REGINALD
Last Name:CHISHOLM, MD
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 1:500 E SWANSON #3
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-357-6180
Mailing Address - Fax:907-357-6184
Practice Address - Street 1:500 E SWANSON #3
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-357-6180
Practice Address - Fax:907-357-6184
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK4075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD12811Medicaid
AKMD12811Medicaid
AKK151310Medicare ID - Type Unspecified