Provider Demographics
NPI:1437127065
Name:DAVIDSON, BRENT RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RYAN
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 1:1011 BOWLES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2395
Mailing Address - Country:US
Mailing Address - Phone:636-717-1700
Mailing Address - Fax:636-203-4727
Practice Address - Street 1:1011 BOWLES AVE
Practice Address - Street 2:SUITE 415
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2395
Practice Address - Country:US
Practice Address - Phone:636-717-1700
Practice Address - Fax:636-203-4727
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005009915207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10032015OtherBLUECROSS BLUESHIELD
ILP00339415OtherRAILROAD MEDICARE
714579OtherHEALTHLINK
IL714579OtherHEALTHLINK
MO109208OtherHEALTH ALLIANCE
MOP00238356OtherRAILROAD MEDICARE
IL113109OtherHEALTH ALLIANCE
MO226523OtherGROUP HEALTH PLAN
MO207319807Medicaid
MO5617586OtherFIRST HEALTH
753168118OtherUNITED HEALTHCARE
MO199422OtherBLUE CROSS BLUE SHIELD
MO199422OtherBLUE CROSS BLUE SHIELD
MO5617586OtherFIRST HEALTH
ILP00339415OtherRAILROAD MEDICARE