1972597896 NPI number — AARON M DEMEYERE MD

Table of content: AARON M DEMEYERE MD (NPI 1972597896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972597896 NPI number — AARON M DEMEYERE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMEYERE
Provider First Name:
AARON
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1972597896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/25/2006
NPI Reactivation Date:
09/11/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1623 5TH ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-758-1102
Provider Business Mailing Address Fax Number:
509-758-1361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1623 5TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-1102
Provider Business Practice Location Address Fax Number:
509-758-1361
Provider Enumeration Date:
09/07/2005

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: 207V00000X , with the licence number:  MD00033091 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: M4776 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 994030000 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 47761 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00078763 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000254500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010005706 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1000298 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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