Provider Demographics
NPI:1760894323
Name:DAVIDSON, DREW (DPM)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 SW BROOKSIDE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-5244
Mailing Address - Country:US
Mailing Address - Phone:515-500-6568
Mailing Address - Fax:515-393-6171
Practice Address - Street 1:255 SW BROOKSIDE DR
Practice Address - Street 2:STE 200
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-5244
Practice Address - Country:US
Practice Address - Phone:515-500-6568
Practice Address - Fax:515-393-6171
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA086108213E00000X
WI1089213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2207464Medicaid
IA086108OtherSTATE LICENSE