Provider Demographics
NPI:1649218777
Name:DAVIDOVICH, GREG W (DC)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:W
Last Name:DAVIDOVICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92248
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0103
Mailing Address - Country:US
Mailing Address - Phone:817-421-9111
Mailing Address - Fax:
Practice Address - Street 1:680 N CARROLL AVE
Practice Address - Street 2:120
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6411
Practice Address - Country:US
Practice Address - Phone:817-421-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U7605OtherBCBS
TX8F5355Medicare PIN
TX8U7605OtherBCBS