Provider Demographics
NPI:1790948164
Name:DAVIDSON, WARREN K (DO)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:K
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 1:21 CAMERON DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8303
Mailing Address - Country:US
Mailing Address - Phone:330-861-8996
Mailing Address - Fax:
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-202-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH340103062080P0204X
FLOS127142080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0057305Medicaid
OHH047910Medicare PIN