Healthcare Provider Details

I. General information

NPI: 1780683052
Provider Name (Legal Business Name): MARY ELIZABETH DAVIDIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 EXECUTIVE DR
NEW WINDSOR NY
12553-5509
US

IV. Provider business mailing address

140 EXECUTIVE DR
NEW WINDSOR NY
12553-5509
US

V. Phone/Fax

Practice location:
  • Phone: 845-562-0138
  • Fax: 845-562-0147
Mailing address:
  • Phone: 845-562-0138
  • Fax: 845-562-0147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number186794
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: