1760428023 NPI number — JUDITH LYNN DAVISON AU.D.

Table of content: JUDITH LYNN DAVISON AU.D. (NPI 1760428023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760428023 NPI number — JUDITH LYNN DAVISON AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVISON
Provider First Name:
JUDITH
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
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:
1760428023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2080 WOODWINDS DRIVE
Provider Second Line Business Mailing Address:
#240
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-702-0750
Provider Business Mailing Address Fax Number:
651-645-6166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
393 N DUNLAP ST
Provider Second Line Business Practice Location Address:
#600
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-645-0691
Provider Business Practice Location Address Fax Number:
651-603-8100
Provider Enumeration Date:
06/22/2006

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: 231H00000X , with the licence number:  5414 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 336725800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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