Provider Demographics
NPI:1598783201
Name:EDWARD D DAVILA, MD PLLC
Entity Type:Organization
Organization Name:EDWARD D DAVILA, MD PLLC
Other - Org Name:BURIEN MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-242-5400
Mailing Address - Street 1:629 SW 153RD ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2216
Mailing Address - Country:US
Mailing Address - Phone:206-242-5400
Mailing Address - Fax:
Practice Address - Street 1:629 SW 153RD ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2216
Practice Address - Country:US
Practice Address - Phone:206-242-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028087207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAE62223Medicare UPIN