Provider Demographics
NPI:1043480056
Name:DAVIDSON, JOHN HOWARD (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HOWARD
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16091 SWINGLEY RIDGE RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2056
Mailing Address - Country:US
Mailing Address - Phone:636-728-2200
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-457-0469
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085001572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001572OtherILLINOIS LICENSE
IL214881041Medicare PIN