Provider Demographics
NPI:1750451381
Name:GARY M. DAVIDSON, MD
Entity Type:Organization
Organization Name:GARY M. DAVIDSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-479-4034
Mailing Address - Street 1:207 WOODSTOWN HWY
Mailing Address - Street 2:
Mailing Address - City:HOLLSOPPLE
Mailing Address - State:PA
Mailing Address - Zip Code:15935-7119
Mailing Address - Country:US
Mailing Address - Phone:814-479-4034
Mailing Address - Fax:814-479-7166
Practice Address - Street 1:207 WOODSTOWN HWY
Practice Address - Street 2:
Practice Address - City:HOLLSOPPLE
Practice Address - State:PA
Practice Address - Zip Code:15935-7119
Practice Address - Country:US
Practice Address - Phone:814-479-4034
Practice Address - Fax:814-479-7166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040789L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011635930006Medicaid
PA444015OtherHIGHMARK
PA444015OtherHIGHMARK
PA0011635930006Medicaid