Provider Demographics
NPI:1295701704
Name:DAVIDSON, P. CARL (MD)
Entity type:Individual
Prefix:
First Name:P.
Middle Name:CARL
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 1:1403 CINDERELLA RD
Mailing Address - Street 2:
Mailing Address - City:LOOKOUT MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30750-2610
Mailing Address - Country:US
Mailing Address - Phone:706-936-8300
Mailing Address - Fax:
Practice Address - Street 1:10366 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30747-1471
Practice Address - Country:US
Practice Address - Phone:706-857-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2024-12-18
Deactivation Date:2008-09-17
Deactivation Code:
Reactivation Date:2008-09-30
Provider Licenses
StateLicense IDTaxonomies
GA029861207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00348895AMedicaid
GAGRP2997Medicare PIN
GA00348895AMedicaid