Healthcare Provider Details

I. General information

NPI: 1083623912
Provider Name (Legal Business Name): ROBERT R DAVIDSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER RD
BERLIN VT
05602-9516
US

IV. Provider business mailing address

14 N PINNACLE RIDGE RD
WATERBURY VT
05676-9140
US

V. Phone/Fax

Practice location:
  • Phone: 802-225-7000
  • Fax:
Mailing address:
  • Phone: 802-244-0850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number550030361
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: