Provider Demographics
NPI:1700873817
Name:DAVIDSON, J THOMAS (MD)
Entity Type:Individual
Prefix:MR
First Name:J
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 1:1 MORNING GLORY CT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-9413
Mailing Address - Country:US
Mailing Address - Phone:609-921-7522
Mailing Address - Fax:
Practice Address - Street 1:281 WITHERSPOON ST
Practice Address - Street 2:SUITE 120
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-3210
Practice Address - Country:US
Practice Address - Phone:609-921-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02846700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3745007Medicaid
D90468Medicare UPIN
NJ3745007Medicaid