Provider Demographics
NPI:1053526137
Name:EMERSON, DAVID JONATHAN (LMT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JONATHAN
Last Name:EMERSON
Suffix:
Gender:M
Credentials:LMT
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 182
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-0182
Mailing Address - Country:US
Mailing Address - Phone:503-618-9760
Mailing Address - Fax:
Practice Address - Street 1:329 NE HOOD AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7449
Practice Address - Country:US
Practice Address - Phone:503-618-9760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7087172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR202629868OtherTIN #