Provider Demographics
NPI:1134224157
Name:DAVISON, PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:DAVISON
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 1:776 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-1698
Mailing Address - Country:US
Mailing Address - Phone:908-241-7800
Mailing Address - Fax:
Practice Address - Street 1:776 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-1698
Practice Address - Country:US
Practice Address - Phone:908-241-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA01936500208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC62982Medicare UPIN
NJ577394BU8Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER