Healthcare Provider Details

I. General information

NPI: 1043865082
Provider Name (Legal Business Name): SEAN LUKE DAVIDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 04/11/2020
Certification Date: 04/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 MALLOY ST
LITTLE ROCK AR
72204-4480
US

IV. Provider business mailing address

3305 MALLOY ST
LITTLE ROCK AR
72204-4480
US

V. Phone/Fax

Practice location:
  • Phone: 501-412-5520
  • Fax:
Mailing address:
  • Phone: 501-412-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberN-7808
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberAR3886
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: