Provider Demographics
NPI:1770163909
Name:DAVIDOW, AUSTIN PHILIP (DPM)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:PHILIP
Last Name:DAVIDOW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1183 NEW HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-5033
Mailing Address - Country:US
Mailing Address - Phone:203-723-7884
Mailing Address - Fax:203-723-2946
Practice Address - Street 1:1183 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-5033
Practice Address - Country:US
Practice Address - Phone:203-723-7884
Practice Address - Fax:203-723-2946
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1164213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008126897Medicaid