Provider Demographics
NPI:1780639385
Name:DAVIDSON, LEE W (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:W
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11840
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1840
Mailing Address - Country:US
Mailing Address - Phone:800-511-4875
Mailing Address - Fax:
Practice Address - Street 1:1460 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4112
Practice Address - Country:US
Practice Address - Phone:541-726-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21966207P00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134240Medicaid
G67421Medicare UPIN
OR134240Medicaid