Provider Demographics
NPI:1225510639
Name:DAVIDSON, DEREK J (PTA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3961 COUNTY ROAD 1120
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-7407
Mailing Address - Country:US
Mailing Address - Phone:903-752-4385
Mailing Address - Fax:
Practice Address - Street 1:300 CHERRY ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:TX
Practice Address - Zip Code:75758-9636
Practice Address - Country:US
Practice Address - Phone:903-849-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2087336225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2087336Medicaid