Provider Demographics
NPI:1184633133
Name:DAVIDSON, MARTIN A (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
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 1:1479 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:KEESEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12944-2330
Mailing Address - Country:US
Mailing Address - Phone:518-834-9310
Mailing Address - Fax:518-834-1148
Practice Address - Street 1:15 DEGRANDPRE WAY
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6449
Practice Address - Country:US
Practice Address - Phone:518-834-9310
Practice Address - Fax:518-834-1148
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201408207ZB0001X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2329109792Medicare PIN
NY232911Medicare PIN
NY2329109791Medicare PIN
G60446Medicare UPIN
NYIA1240Medicare PIN