Provider Demographics
NPI:1972545143
Name:DAVILA, EDWARD D (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:D
Last Name:DAVILA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:323 E RIVERSIDE DR STE 224
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6865
Mailing Address - Country:US
Mailing Address - Phone:208-302-6000
Mailing Address - Fax:208-302-6055
Practice Address - Street 1:323 E RIVERSIDE DR STE 224
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6865
Practice Address - Country:US
Practice Address - Phone:208-302-6000
Practice Address - Fax:208-302-6055
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028087207R00000X
IDMC-1136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2110721Medicaid