1467410043 NPI number — DR. MELISSA DAVIDSON MD

Table of content: DR. MELISSA DAVIDSON MD (NPI 1467410043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467410043 NPI number — DR. MELISSA DAVIDSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
MELISSA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467410043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 GRAND AVENUE
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-568-3262
Provider Business Mailing Address Fax Number:
201-589-2634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 GRAND AVENUE
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-568-3262
Provider Business Practice Location Address Fax Number:
201-589-2634
Provider Enumeration Date:
05/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MA056284 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2080A0000X , with the licence number: MA056284 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BP169 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4573706 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".