Provider Demographics
NPI:1609959857
Name:DAVIDOV, MICHAEL S (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:DAVIDOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34509 9TH AVENUE SOUTH
Mailing Address - Street 2:#207
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-815-9595
Mailing Address - Fax:253-815-9797
Practice Address - Street 1:34509 9TH AVENUE SOUTH
Practice Address - Street 2:#207
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003
Practice Address - Country:US
Practice Address - Phone:253-815-9595
Practice Address - Fax:253-815-9797
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034406207V00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
146075OtherL&I
WA1113661Medicaid
146075OtherL1
WA7900749Medicaid
H05885Medicare UPIN
AB20523Medicare ID - Type Unspecified
5452660001Medicare NSC
WA7900749Medicaid