Healthcare Provider Details

I. General information

NPI: 1417948522
Provider Name (Legal Business Name): MARK BENJAMIN DAVIDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MAIN ST
NORTHBOROUGH MA
01532-1914
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-393-9503
  • Fax: 508-393-9670
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number218842
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: