Provider Demographics
NPI:1770583734
Name:DAVIDSON, LORI L (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N STATE ROAD 135 STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1352
Mailing Address - Country:US
Mailing Address - Phone:317-893-3131
Mailing Address - Fax:317-893-2445
Practice Address - Street 1:107 N STATE ROAD 135
Practice Address - Street 2:SUITE 102
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1351
Practice Address - Country:US
Practice Address - Phone:317-893-3131
Practice Address - Fax:317-893-3141
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037737A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100194210AMedicaid
IN247030AMedicare PIN
IN100194210AMedicaid