Provider Demographics
NPI:1689648396
Name:DAVIDSON, KENT WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:WALLACE
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S MCKINLEY ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5202
Mailing Address - Country:US
Mailing Address - Phone:501-663-3647
Mailing Address - Fax:501-663-1706
Practice Address - Street 1:600 S MCKINLEY ST
Practice Address - Street 2:SUITE 405
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5202
Practice Address - Country:US
Practice Address - Phone:501-663-3647
Practice Address - Fax:501-663-1706
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5045174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR51294Medicare ID - Type Unspecified
ARB90115Medicare UPIN