=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750451381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARY M. DAVIDSON, MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 WOODSTOWN HWY
-----------------------------------------------------
City | HOLLSOPPLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15935-7119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-479-4034
-----------------------------------------------------
Fax | 814-479-7166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 WOODSTOWN HWY
-----------------------------------------------------
City | HOLLSOPPLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15935-7119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-479-4034
-----------------------------------------------------
Fax | 814-479-7166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | GARY M DAVIDSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 814-479-4034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD040789L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------