Provider Demographics
NPI:1063679116
Name:DAVIDSON, DAVID JEREMY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JEREMY
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 WAUKEGAN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1885
Mailing Address - Country:US
Mailing Address - Phone:847-663-8410
Mailing Address - Fax:847-267-1429
Practice Address - Street 1:2151 WAUKEGAN RD STE 100
Practice Address - Street 2:
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1885
Practice Address - Country:US
Practice Address - Phone:847-663-8410
Practice Address - Fax:847-267-1429
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125260207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine