Provider Demographics
NPI:1033770532
Name:DAVIDSON, TAVARAS (MA, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:TAVARAS
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 E MCKINNEY ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-4630
Mailing Address - Country:US
Mailing Address - Phone:217-390-6714
Mailing Address - Fax:
Practice Address - Street 1:5101 E MCKINNEY ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-4630
Practice Address - Country:US
Practice Address - Phone:217-390-6714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer