Provider Demographics
NPI:1043941586
Name:DAVIDEK, ELLEN REA (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:REA
Last Name:DAVIDEK
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 1:1632 STONE ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-685-6922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351052998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program