Provider Demographics
NPI:1043865082
Name:DAVIDSON, SEAN LUKE
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:LUKE
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 MALLOY ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-4480
Mailing Address - Country:US
Mailing Address - Phone:501-412-5520
Mailing Address - Fax:
Practice Address - Street 1:3305 MALLOY ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-4480
Practice Address - Country:US
Practice Address - Phone:501-412-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-78082084B0040X
ARAR3886208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR040114Medicaid