Provider Demographics
NPI:1265434500
Name:DAVIDSON, JOHN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
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 1:1300 36TH ST
Mailing Address - Street 2:STE 1H
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4898
Mailing Address - Country:US
Mailing Address - Phone:772-563-0146
Mailing Address - Fax:772-770-5817
Practice Address - Street 1:1300 36TH ST
Practice Address - Street 2:STE 1H
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4898
Practice Address - Country:US
Practice Address - Phone:772-563-0146
Practice Address - Fax:772-770-5817
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044564900Medicaid
FLE21382Medicare UPIN
FL0053369Medicare ID - Type Unspecified