1104909894 NPI number — DR. DAVID MICHAEL COREY PH.D., ABPP

Table of content: DR. DAVID MICHAEL COREY PH.D., ABPP (NPI 1104909894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104909894 NPI number — DR. DAVID MICHAEL COREY PH.D., ABPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COREY
Provider First Name:
DAVID
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., ABPP
Provider Gender Code:
M

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:
1104909894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 895
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97034-0143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-620-8050
Provider Business Mailing Address Fax Number:
503-620-9650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5285 MEADOWS ROAD
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-3367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-620-8050
Provider Business Practice Location Address Fax Number:
503-620-9650
Provider Enumeration Date:
10/24/2006

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: 103TF0200X , with the licence number:  1187 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TF0200X , with the licence number: PY-1941 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: PSY-847 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: PSY-11389 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: 6271762-2501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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