Basic Information
| Provider Information | |||||||||
| NPI: | 1881799591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9040A JACKSON AVE JOINT BASE LEWIS-MCCHORD SUITE #100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539681518 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9040A JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539681518 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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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 | 225100000X | PT10139 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT18080 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | PT18080 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | PT18080 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | PT00010139 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8521478 | 05 | WA | MEDICAID | 0239151 | 01 | WA | L&I | OTHER |