Healthcare Provider Details

I. General information

NPI: 1871565861
Provider Name (Legal Business Name): KENNETH H DAVIDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 PORTLAND AVE SUITE 350
ROCHESTER NY
14621-3038
US

IV. Provider business mailing address

1415 PORTLAND AVE SUITE 350
ROCHESTER NY
14621-3038
US

V. Phone/Fax

Practice location:
  • Phone: 585-426-9278
  • Fax: 585-338-2738
Mailing address:
  • Phone: 585-426-9278
  • Fax: 585-338-2738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number103663
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: