Healthcare Provider Details

I. General information

NPI: 1013697770
Provider Name (Legal Business Name): THOMAS J DAVIDSON IV WNY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SHERIDAN DR
TONAWANDA NY
14150-9462
US

IV. Provider business mailing address

2700 SHERIDAN DR
TONAWANDA NY
14150-9462
US

V. Phone/Fax

Practice location:
  • Phone: 251-747-4401
  • Fax:
Mailing address:
  • Phone: 251-747-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS J DAVIDSON IV
Title or Position: DOCTOR OF PODIATRIC MEDICINE, OWNER
Credential: DPM
Phone: 251-747-4401