Basic Information
| Provider Information | |||||||||
| NPI: | 1174831192 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL S DAVIDOV, MD, INC, PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34509 9TH AVENUE SOUTH | ||||||||
| Address2: | #207 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538159595 | ||||||||
| FaxNumber: | 2538159797 | ||||||||
| Practice Location | |||||||||
| Address1: | 34509 9TH AVENUE SOUTH | ||||||||
| Address2: | #207 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538159595 | ||||||||
| FaxNumber: | 2538159797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2010 | ||||||||
| LastUpdateDate: | 12/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | DAVIDOV | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2538159595 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD00034406 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207V00000X | MD00034406 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | GAB20523 | 01 | WA | PTAN | OTHER | 1113661 | 05 | WA | MEDICAID | 7900749 | 05 | WA | MEDICAID |