Basic Information
| Provider Information | |||||||||
| NPI: | 1225109168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BENJAMIN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037421143 | ||||||||
| FaxNumber: | 6037493509 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 MEMBERS WAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038205933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037421143 | ||||||||
| FaxNumber: | 6037493509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 13393 | NH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 3076450 | 05 | NH | MEDICAID | 1225109168 | 05 | ME | MEDICAID | P00775096 | 01 | NH | RR MEDICARE | OTHER |