Provider Demographics
NPI:1831175280
Name:DAVIDSON, EDWIN M (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:M
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:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1210
Mailing Address - Country:US
Mailing Address - Phone:228-575-1234
Mailing Address - Fax:228-575-1240
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-575-1234
Practice Address - Fax:228-575-1240
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08286207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010316Medicaid
B66033Medicare UPIN
MS00010316Medicaid
110000489Medicare ID - Type Unspecified