Provider Demographics
NPI:1639218829
Name:DAVIDSON, GREG E (CPO)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:E
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11919 CANYON ROAD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5915
Mailing Address - Country:US
Mailing Address - Phone:253-651-8250
Mailing Address - Fax:253-881-1397
Practice Address - Street 1:812 39TH AVE SW
Practice Address - Street 2:SUITE D
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5915
Practice Address - Country:US
Practice Address - Phone:253-651-8250
Practice Address - Fax:253-651-8250
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000306174400000X
WAPS00000207174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist