Provider Demographics
NPI:1235125618
Name:DAVIDSON, LEO WARREN (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:WARREN
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 1:1841 QUIET CV
Mailing Address - Street 2:P O BOX 64367
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3985
Mailing Address - Country:US
Mailing Address - Phone:910-323-2626
Mailing Address - Fax:910-829-6596
Practice Address - Street 1:1841 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3985
Practice Address - Country:US
Practice Address - Phone:910-829-6588
Practice Address - Fax:910-829-6596
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35312208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC020031637OtherMEDICARE RAIL ROAD
NC47806OtherMED COST
NC1738882OtherUNITED HEALTH CARE
NC27271OtherBLUE CROSS BLUE SHIELD
NC8927271Medicaid
NC47806OtherMED COST
NC27271OtherBLUE CROSS BLUE SHIELD