Provider Demographics
NPI:1669419693
Name:DAVIDSON, JAMES RILEY (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RILEY
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130, PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-9753
Practice Address - Country:US
Practice Address - Phone:765-675-8391
Practice Address - Fax:765-675-6704
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12137207P00000X
IN01054498A207P00000X
IDM9214207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807143000Medicaid
IN200377830Medicaid
IN000000851775OtherANTHEM PIN
ID1130214Medicare ID - Type Unspecified
IN200377830Medicaid
ID807143000Medicaid