Provider Demographics
NPI:1083255848
Name:DAVIDSON, LAURA ELLEN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELLEN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 HEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5131
Mailing Address - Country:US
Mailing Address - Phone:610-742-0376
Mailing Address - Fax:
Practice Address - Street 1:411 N MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-4059
Practice Address - Country:US
Practice Address - Phone:610-892-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012188208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation