Provider Demographics
NPI:1528040367
Name:DAVIDSON, PHILIP A (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 PARK AVE BLDG D
Mailing Address - Street 2:STE 100
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7246
Mailing Address - Country:US
Mailing Address - Phone:435-615-8822
Mailing Address - Fax:435-615-8823
Practice Address - Street 1:2200 PARK AVE BLDG D
Practice Address - Street 2:STE 100
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7246
Practice Address - Country:US
Practice Address - Phone:435-615-8822
Practice Address - Fax:435-615-8823
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54865207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2000016351OtherRAILROAD MEDICARE
FL4511587OtherAETNA
FLAVMEDOther258113
FL18987OtherBLUE CROSS BLUE SHIELD
FL373524900Medicaid
FL4511587OtherAETNA
FL373524900Medicaid