Provider Demographics
NPI:1184607806
Name:DAVIDSON, ROBERT CULLEN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CULLEN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:C
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1687
Mailing Address - Country:US
Mailing Address - Phone:616-486-9280
Mailing Address - Fax:616-974-9064
Practice Address - Street 1:2900 BRADFORD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6427
Practice Address - Country:US
Practice Address - Phone:616-885-5000
Practice Address - Fax:616-885-5020
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034558207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4709460Medicaid
MI060053856OtherRAILROAD MEDICARE
MIA74760Medicare UPIN
MI060053856OtherRAILROAD MEDICARE