Provider Demographics
NPI:1245235217
Name:DAVIDSON, DWIGHT DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:DOUGLAS
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 3686
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-0686
Mailing Address - Country:US
Mailing Address - Phone:910-442-1100
Mailing Address - Fax:910-442-1199
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-442-1100
Practice Address - Fax:910-442-1199
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400231207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2200981HOtherMEDICARE PTAN
NC2200981FOtherMEDICARE PTAN
NC8927157Medicaid
NC8927157Medicaid
NC2200981DMedicare ID - Type Unspecified
NC2200981FOtherMEDICARE PTAN