Provider Demographics
NPI:1790721827
Name:DAVIS, KURT W (DPM)
Entity Type:Individual
Prefix:MR
First Name:KURT
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 SE 165TH AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:360-694-3668
Mailing Address - Fax:360-882-3566
Practice Address - Street 1:2415 SE 165TH AVE
Practice Address - Street 2:STE 104
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-694-3668
Practice Address - Fax:360-882-3566
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAP000000682213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1121235Medicaid
WA6444400001OtherPTAN
U72413Medicare UPIN
WA6444400001OtherPTAN
WA1121235Medicaid