Provider Demographics
NPI:1598470023
Name:DAVIDSON, TRUMAN
Entity Type:Individual
Prefix:
First Name:TRUMAN
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S 900 E APT 107
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4157
Mailing Address - Country:US
Mailing Address - Phone:915-269-6040
Mailing Address - Fax:
Practice Address - Street 1:27 S MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5888
Practice Address - Country:US
Practice Address - Phone:915-269-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0812871170Medicaid