Provider Demographics
NPI:1003956673
Name:DAVIDSON, RICHARD MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 TYSONS CORNER CTR
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4525
Mailing Address - Country:US
Mailing Address - Phone:703-893-6586
Mailing Address - Fax:703-893-9379
Practice Address - Street 1:8025 TYSONS CORNER CTR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4525
Practice Address - Country:US
Practice Address - Phone:703-893-6586
Practice Address - Fax:703-893-9379
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001827152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT-87936Medicare UPIN
VA1C 571367Medicare PIN