1629079686 NPI number — MR. DAVID LEON DORA D.O.

Table of content: MR. DAVID LEON DORA D.O. (NPI 1629079686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629079686 NPI number — MR. DAVID LEON DORA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORA
Provider First Name:
DAVID
Provider Middle Name:
LEON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DORA
Provider Other First Name:
DAVID
Provider Other Middle Name:
LEON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1629079686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1848
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSKEGON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49443-1848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-727-4444
Provider Business Mailing Address Fax Number:
231-728-4789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3443 FARR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITPORT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49415-8779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-672-2900
Provider Business Practice Location Address Fax Number:
231-672-2901
Provider Enumeration Date:
08/02/2005

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: 207Q00000X , with the licence number:  5101007779 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2590390 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112590390 . This is a "MUSKEGON CARE/ACCESS HEAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101635 . This is a "PREFERRED CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 102 . This is a "COMMUNITY CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 18799 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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