Provider Demographics
NPI:1598714867
Name:DAVIDSON, RICHARD TREVOR (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:TREVOR
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:2603 W PLEASANT GROVE RD
Practice Address - Street 2:STE 104
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-5804
Practice Address - Country:US
Practice Address - Phone:479-636-1187
Practice Address - Fax:479-636-1197
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014034142225100000X
ARPT 2893225100000X
GAPT009386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159990721Medicaid
AR71085780150OtherQUALCHOICE
AR445934001OtherPALMETTO GI DME
AR662725OtherHEALTHLINK
MO791200OtherBCBS-ANTHEM
MOMA4370090OtherMEDICARE PTAN
AR159990721Medicaid
AR71085780150OtherQUALCHOICE