Healthcare Provider Details

I. General information

NPI: 1174831192
Provider Name (Legal Business Name): MICHAEL S DAVIDOV, MD, INC, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34509 9TH AVENUE SOUTH #207
FEDERAL WAY WA
98003-8709
US

IV. Provider business mailing address

34509 9TH AVENUE SOUTH #207
FEDERAL WAY WA
98003-8709
US

V. Phone/Fax

Practice location:
  • Phone: 253-815-9595
  • Fax: 253-815-9797
Mailing address:
  • Phone: 253-815-9595
  • Fax: 253-815-9797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD00034406
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD00034406
License Number StateWA

VIII. Authorized Official

Name: MICHAEL S DAVIDOV
Title or Position: PRESIDENT
Credential: MD
Phone: 253-815-9595