Provider Demographics
NPI:1851616155
Name:DAVIDSON, JOHN CARL JR (DPT,MOTR)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CARL
Last Name:DAVIDSON
Suffix:JR
Gender:M
Credentials:DPT,MOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3347 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3842
Mailing Address - Country:US
Mailing Address - Phone:318-443-3311
Mailing Address - Fax:
Practice Address - Street 1:3347 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3842
Practice Address - Country:US
Practice Address - Phone:318-443-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07340225100000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3B698CH69OtherMEDICARE PTAN
1851616155OtherNPI