Provider Demographics
NPI:1508858184
Name:DAVIDSON, VANDA L (MD)
Entity Type:Individual
Prefix:
First Name:VANDA
Middle Name:L
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 1:201 4TH ST
Mailing Address - Street 2:BOX 30102
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8421
Mailing Address - Country:US
Mailing Address - Phone:318-443-4514
Mailing Address - Fax:
Practice Address - Street 1:201 4TH ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:318-443-4514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012793207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1307904Medicaid
LA1307904Medicaid
LA5L132Medicare PIN