Provider Demographics
NPI:1740240902
Name:DAVIDSON, MICHAEL JAMES (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-359-0019
Mailing Address - Fax:931-359-7381
Practice Address - Street 1:1090 N ELLINGTON PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2227
Practice Address - Country:US
Practice Address - Phone:913-359-0019
Practice Address - Fax:931-359-7381
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3130078OtherBLUE CROSS NUMBER
TN3710089Medicaid
TN3302360Medicaid
TN3130078OtherBLUE CROSS NUMBER
TN3302360Medicare ID - Type UnspecifiedMEDICARE NUMBER
3710089Medicare PIN