Provider Demographics
NPI:1750850400
Name:DAVIDSON, SADE
Entity Type:Individual
Prefix:
First Name:SADE
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25926 CRAFT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3031
Mailing Address - Country:US
Mailing Address - Phone:347-869-3045
Mailing Address - Fax:
Practice Address - Street 1:25926 CRAFT AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3031
Practice Address - Country:US
Practice Address - Phone:347-869-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1278098181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18060026OtherHIP HMO