Provider Demographics
NPI:1013944016
Name:DAVIDSON, BENTON JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENTON
Middle Name:JOHN
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 1:1174 CORNUCOPIA ST NW
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3193
Mailing Address - Country:US
Mailing Address - Phone:503-385-1664
Mailing Address - Fax:503-991-5768
Practice Address - Street 1:1174 CORNUCOPIA ST NW
Practice Address - Street 2:SUITE 240
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3193
Practice Address - Country:US
Practice Address - Phone:503-385-1664
Practice Address - Fax:503-991-5768
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD216432084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288103Medicaid
ORG03664Medicare UPIN
OR288103Medicaid