Provider Demographics
NPI:1316195910
Name:DAVIDSON, DAVID WALLACE (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WALLACE
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11160 VEIRS MILL RD SPC G1
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2542
Mailing Address - Country:US
Mailing Address - Phone:301-949-3960
Mailing Address - Fax:301-949-2429
Practice Address - Street 1:11160 VEIRS MILL RD SPC G1
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902-2542
Practice Address - Country:US
Practice Address - Phone:301-949-3960
Practice Address - Fax:301-949-2429
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist