Provider Demographics
NPI:1407885833
Name:DAVIDSON, LAURA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5019 LAVISTA RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3541
Mailing Address - Country:US
Mailing Address - Phone:678-534-0452
Mailing Address - Fax:678-534-1534
Practice Address - Street 1:5019 LAVISTA RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3541
Practice Address - Country:US
Practice Address - Phone:678-534-0452
Practice Address - Fax:678-534-1534
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028960207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11BDQSPMedicare ID - Type Unspecified
GAD39687Medicare UPIN
GA00335838KMedicaid