Provider Demographics
NPI:1689787905
Name:DAVISON, EDWIN A JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:A
Last Name:DAVISON
Suffix:JR
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 1:615 MAPLE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5632
Mailing Address - Country:US
Mailing Address - Phone:518-584-5821
Mailing Address - Fax:518-583-9404
Practice Address - Street 1:615 MAPLE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5632
Practice Address - Country:US
Practice Address - Phone:518-584-5821
Practice Address - Fax:518-583-9404
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182490174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01410975Medicaid
NYBB5683Medicare PIN
NY4964430001Medicare NSC
NYF51611Medicare UPIN