1619934023 NPI number — GREGORY STEVEN DAVIDSON PA

Table of content: GREGORY STEVEN DAVIDSON PA (NPI 1619934023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619934023 NPI number — GREGORY STEVEN DAVIDSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIDSON
Provider First Name:
GREGORY
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

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:
1619934023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
856 J CLYDE MORRIS BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23601-1318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
895 MIDDLE GROUND BLVD
Provider Second Line Business Practice Location Address:
SUITE 152
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23606-4250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-599-5505
Provider Business Practice Location Address Fax Number:
757-599-3618
Provider Enumeration Date:
04/28/2006

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: 363A00000X , with the licence number:  0110001809 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1619934023 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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