Provider Demographics
NPI:1790747954
Name:DAVIS, TAD LEON (MD)
Entity Type:Individual
Prefix:
First Name:TAD
Middle Name:LEON
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:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0577
Mailing Address - Country:US
Mailing Address - Phone:509-689-2517
Mailing Address - Fax:509-689-2086
Practice Address - Street 1:507 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812-0507
Practice Address - Country:US
Practice Address - Phone:509-689-2517
Practice Address - Fax:509-689-2086
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1349703Medicaid
WAE17476Medicare UPIN