Provider Demographics
NPI:1033187679
Name:DAVIS, ROBERT B (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SW 10TH AVE
Mailing Address - Street 2:STE 1110
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2426
Mailing Address - Country:US
Mailing Address - Phone:503-841-5642
Mailing Address - Fax:
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:THE VANCOUVER CLINIC
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-397-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021030E207R00000X
WAMD00046696207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8464380Medicaid
PA0006790590003Medicaid
C30662Medicare UPIN
PA0006790590003Medicaid