Provider First Line Business Practice Location Address: 
2400 DAVIDSON AVE
    Provider Second Line Business Practice Location Address: 
DAVIDSON PEDIATRIC CENTER
    Provider Business Practice Location Address City Name: 
NEW JERSEY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
07450
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-933-4034
    Provider Business Practice Location Address Fax Number: 
718-933-0440
    Provider Enumeration Date: 
09/08/2009