Provider Demographics
NPI:1366483109
Name:IRVINE, DAVID NERSETH (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:NERSETH
Last Name:IRVINE
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 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1809 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1939
Practice Address - Country:US
Practice Address - Phone:503-357-2173
Practice Address - Fax:503-357-2318
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15519207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6751HUOtherBSWA
WA8240871Medicaid
WA8946238OtherVCR
OR059253Medicaid
WA0216865OtherLIWA
WAG8865277Medicare PIN
WA8946238OtherVCR
WA0216865OtherLIWA
ORA49426Medicare UPIN
ORP00308819Medicare PIN