Healthcare Provider Details

I. General information

NPI: 1790774826
Provider Name (Legal Business Name): ROBERT J DAVIDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 N WALNUT ST
PINCKNEYVILLE IL
62274-1050
US

IV. Provider business mailing address

3702 SHOSHONE CIR
PINCKNEYVILLE IL
62274-4113
US

V. Phone/Fax

Practice location:
  • Phone: 618-357-2147
  • Fax: 618-357-8142
Mailing address:
  • Phone: 618-357-2147
  • Fax: 618-357-8142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36-079086
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: