Provider Demographics
NPI:1942246707
Name:DAVIDSON, RICKY GARLAND (MD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:GARLAND
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 MCELHANEY RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1734
Practice Address - Country:US
Practice Address - Phone:864-834-3192
Practice Address - Fax:864-241-9234
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024159207Q00000X
SC87801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1571245Medicaid
SCPENDINGMedicaid
LA1571245Medicaid
LA4A023Medicare PIN
LAH08770Medicare UPIN