Provider Demographics
NPI:1013697770
Name:THOMAS J DAVIDSON IV WNY LLC
Entity Type:Organization
Organization Name:THOMAS J DAVIDSON IV WNY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:IV
Authorized Official - Credentials:DPM
Authorized Official - Phone:251-747-4401
Mailing Address - Street 1:2700 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-9462
Mailing Address - Country:US
Mailing Address - Phone:251-747-4401
Mailing Address - Fax:
Practice Address - Street 1:2700 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-9462
Practice Address - Country:US
Practice Address - Phone:251-747-4401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-18
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty