Healthcare Provider Details

I. General information

NPI: 1558883546
Provider Name (Legal Business Name): LUCAS DAVIDSON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 COMMED BLVD
ORANGE CITY FL
32763-8321
US

IV. Provider business mailing address

3901 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4312
US

V. Phone/Fax

Practice location:
  • Phone: 386-775-7488
  • Fax:
Mailing address:
  • Phone: 904-345-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: