Provider Demographics
NPI:1669647731
Name:MCDAVID, MARK EVANDER (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EVANDER
Last Name:MCDAVID
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARK WEST CIR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5551
Mailing Address - Country:US
Mailing Address - Phone:804-855-4086
Mailing Address - Fax:
Practice Address - Street 1:1 PARK WEST CIR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-5551
Practice Address - Country:US
Practice Address - Phone:804-855-4086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2948225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist