Provider Demographics
NPI:1225017783
Name:DAVIDSON, MARC ROMAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:ROMAYNE
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 1:24076 SE STARK
Mailing Address - Street 2:STE 110
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-661-5388
Mailing Address - Fax:503-666-3393
Practice Address - Street 1:24076 SE STARK
Practice Address - Street 2:STE 110
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-661-5388
Practice Address - Fax:503-666-3393
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17775207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G36974Medicare UPIN
109426Medicare ID - Type Unspecified