Provider Demographics
NPI:1861493744
Name:DAVIDSON, DAVID S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:S
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2744
Mailing Address - Country:US
Mailing Address - Phone:973-571-2121
Mailing Address - Fax:
Practice Address - Street 1:347 MT PLEASANT AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2537
Practice Address - Country:US
Practice Address - Phone:973-571-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00095900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ066531Medicare PIN
P78730Medicare UPIN
NJ243643TC40Medicare PIN