Provider Demographics
NPI:1174831192
Name:MICHAEL S DAVIDOV, MD, INC, PS
Entity Type:Organization
Organization Name:MICHAEL S DAVIDOV, MD, INC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIDOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-815-9595
Mailing Address - Street 1:34509 9TH AVENUE SOUTH
Mailing Address - Street 2:#207
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8709
Mailing Address - Country:US
Mailing Address - Phone:253-815-9595
Mailing Address - Fax:253-815-9797
Practice Address - Street 1:34509 9TH AVENUE SOUTH
Practice Address - Street 2:#207
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8709
Practice Address - Country:US
Practice Address - Phone:253-815-9595
Practice Address - Fax:253-815-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034406207V00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB20523OtherPTAN
WA1113661Medicaid
WA7900749Medicaid
WA1113661Medicaid
5452660001Medicare NSC