Provider Demographics
NPI:1053374157
Name:KISHBAUGH, DAVID (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KISHBAUGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41054
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-1054
Mailing Address - Country:US
Mailing Address - Phone:910-486-8880
Mailing Address - Fax:910-486-8886
Practice Address - Street 1:2109 VALLEYGATE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3571
Practice Address - Country:US
Practice Address - Phone:910-486-8880
Practice Address - Fax:910-486-8886
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500379208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8949528Medicaid
G07259Medicare UPIN
NC2215189BMedicare ID - Type Unspecified