MEDICARE: COLEMAN WADE DAVIDSON II M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	13613	TN
2	207VX0000X	Obstetrics Physician	53209	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	53209	OTHER	AZ	AZ STATE LICENSE

General Provider Information

NPI Number	:	1013910157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLEMAN WADE DAVIDSON II M.D.

Provider Business Mailing Address
First Line	:	PO BOX 31235
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85751-1235
Country	:	US
Telephone Number	:	520-324-4100
Fax Number	:	520-324-1406

Provider Business Practice Location Address
First Line	:	5301 E GRANT RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-2805
Country	:	US
Telephone Number	:	520-795-8188
Fax Number	:	520-325-0809

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	09/13/2021

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