Healthcare Provider Details

I. General information

NPI: 1821083304
Provider Name (Legal Business Name): ALTON G DAVIDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 RIDGE AVE SW
ATLANTA GA
30315-1640
US

IV. Provider business mailing address

1046 RIDGE AVE SW
ATLANTA GA
30315-1640
US

V. Phone/Fax

Practice location:
  • Phone: 404-688-1350
  • Fax: 404-564-6734
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number025503
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: