Healthcare Provider Details

I. General information

NPI: 1699708412
Provider Name (Legal Business Name): MARSON T DAVIDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE MAIN BUILDING RM 5640
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE MAIN BUILDING RM 5640
HACKENSACK NJ
07601-1914
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-4218
  • Fax: 201-996-4833
Mailing address:
  • Phone: 201-996-4218
  • Fax: 201-996-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07449200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: