Provider Demographics
NPI:1245839000
Name:DAVIDSON, CHARLES JORDAN (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JORDAN
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-2060
Mailing Address - Country:US
Mailing Address - Phone:606-217-0920
Mailing Address - Fax:859-275-2130
Practice Address - Street 1:1824 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1020
Practice Address - Country:US
Practice Address - Phone:606-217-0920
Practice Address - Fax:606-217-0922
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2203DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist