Provider Demographics
NPI:1962404640
Name:MAGNUSEN, DAVID KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KENNETH
Last Name:MAGNUSEN
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 1:25 TYLER CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8301
Mailing Address - Country:US
Mailing Address - Phone:937-212-4801
Mailing Address - Fax:937-866-1798
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417
Practice Address - Country:US
Practice Address - Phone:937-212-4801
Practice Address - Fax:937-886-1978
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-6525-M208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2242700Medicaid
OHP01686214Medicare PIN
OH2242700Medicaid
OH4055411Medicare PIN
OHH346350Medicare PIN