Provider Demographics
NPI:1093705022
Name:DAVIDSON, ELAINE M (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:M
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:MARTIN
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:
Practice Address - Street 1:875 S VANGUARD WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7552
Practice Address - Country:US
Practice Address - Phone:208-468-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003656100Medicaid
ID000010150633OtherBLUE SHIELD
ID74526OtherBLUE CROSS
ID003656100Medicaid
ID000010150633OtherBLUE SHIELD