Provider Demographics
NPI:1356610406
Name:DAVOREN, KATHERINE (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DAVOREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5760
Mailing Address - Country:US
Mailing Address - Phone:401-861-7711
Mailing Address - Fax:401-421-5710
Practice Address - Street 1:1076 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5760
Practice Address - Country:US
Practice Address - Phone:401-861-7711
Practice Address - Fax:401-421-5710
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD17448207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program