1083607014 NPI number — LAURA J DAVIS MD

Table of content: LAURA J DAVIS MD (NPI 1083607014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083607014 NPI number — LAURA J DAVIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
LAURA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083607014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/27/2006
NPI Reactivation Date:
03/31/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14508 NE 20TH AVE
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98686-6418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-695-8553
Provider Business Mailing Address Fax Number:
360-737-3713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14508 NE 20TH AVE
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-6418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-695-8553
Provider Business Practice Location Address Fax Number:
360-737-3713
Provider Enumeration Date:
08/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  MD00043457 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)