Healthcare Provider Details

I. General information

NPI: 1730600370
Provider Name (Legal Business Name): KIRILL DAVIDOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 06/17/2025
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TITUS PLACE
WALTON NY
13856-1455
US

IV. Provider business mailing address

2 TITUS PLACE
WALTON NY
13856-1455
US

V. Phone/Fax

Practice location:
  • Phone: 607-865-2400
  • Fax: 607-865-7305
Mailing address:
  • Phone: 607-865-2400
  • Fax: 607-865-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number301827
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: