Provider Demographics
NPI:1235210634
Name:DAVIDSON, KENDRICK C (MD)
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:C
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5276
Practice Address - Country:US
Practice Address - Phone:573-882-1026
Practice Address - Fax:573-884-8876
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-110282085R0202X
MOR30612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO04778143OtherBCBS KANSAS CITY
KS200317850AMedicaid
MO203727763Medicaid
KS306444OtherFIRSTGUARD
MO04778143OtherBCBS KANSAS CITY
P00229885Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KS306444OtherFIRSTGUARD
KS200317850AMedicaid