Provider Demographics
NPI:1710138391
Name:MICHAEL J. DAVIDSON, O.D., P.C.
Entity Type:Organization
Organization Name:MICHAEL J. DAVIDSON, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-569-6363
Mailing Address - Street 1:8350 TRAFORD LN
Mailing Address - Street 2:FL 2
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1664
Mailing Address - Country:US
Mailing Address - Phone:703-569-6363
Mailing Address - Fax:703-569-3536
Practice Address - Street 1:8350 TRAFORD LN
Practice Address - Street 2:FL 2
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1664
Practice Address - Country:US
Practice Address - Phone:703-569-6363
Practice Address - Fax:703-569-3536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000035332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0712710001Medicare NSC