Provider Demographics
NPI:1356324677
Name:DAVIDOV, ADI (MD)
Entity Type:Individual
Prefix:DR
First Name:ADI
Middle Name:
Last Name:DAVIDOV
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 1:1 EDGEWATER ST
Mailing Address - Street 2:6TH FL. PAYER RELATIONS
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4900
Mailing Address - Country:US
Mailing Address - Phone:718-226-1008
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:440 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3401
Practice Address - Country:US
Practice Address - Phone:718-226-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212520207V00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02568707Medicaid
NYI10629Medicare UPIN
NY02568707Medicaid