1619102050 NPI number — RISA DANIELLE DAVIDSON DO

Table of content: RISA DANIELLE DAVIDSON DO (NPI 1619102050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619102050 NPI number — RISA DANIELLE DAVIDSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
RISA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COHEN
Provider Other First Name:
RISA
Provider Other Middle Name:
DANIELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619102050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12740 MEETING HOUSE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-7292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-343-8844
Provider Business Mailing Address Fax Number:
540-274-8548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12740 MEETING HOUSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46032-7292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-343-8844
Provider Business Practice Location Address Fax Number:
540-274-8548
Provider Enumeration Date:
05/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  02003938A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01456972 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201067930 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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