Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 025503 | GA |
NPI | 1821083304 |
---|---|
Provider Name | Alton G Davidson |
First Address | Atlanta, GA 30315-1640 |
Second Address | Atlanta, GA 30315-1640 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D39690 | (02) | GA |