Healthcare Provider Details

I. General information

NPI: 1164712931
Provider Name (Legal Business Name): DAIVA NEVIDOMSKYTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 YAKIMA AVE STE 204
TACOMA WA
98405-5304
US

IV. Provider business mailing address

1802 YAKIMA AVE STE 204
TACOMA WA
98405-5304
US

V. Phone/Fax

Practice location:
  • Phone: 253-382-8540
  • Fax: 253-382-8545
Mailing address:
  • Phone: 253-382-8540
  • Fax: 253-382-8545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD60804832
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: