Healthcare Provider Details

I. General information

NPI: 1043573595
Provider Name (Legal Business Name): BENJAMIN DAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 07/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MADISON ST STE 400
SEATTLE WA
98104-1316
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-6111
  • Fax: 206-386-6113
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML60293615
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60490088
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: