Provider Demographics
NPI:1497827851
Name:DAVIDSON, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
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:PO BOX 8129
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49518-8129
Mailing Address - Country:US
Mailing Address - Phone:616-734-0335
Mailing Address - Fax:616-949-8540
Practice Address - Street 1:1705 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-3246
Practice Address - Country:US
Practice Address - Phone:616-734-0335
Practice Address - Fax:616-949-8540
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5153207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138435613Medicaid
TX8C2316Medicare PIN