Provider Demographics
NPI:1104874197
Name:DAVIDSON, BRENT WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WILLIAM
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:HIAWASSEE
Mailing Address - State:GA
Mailing Address - Zip Code:30546-0509
Mailing Address - Country:US
Mailing Address - Phone:706-896-2222
Mailing Address - Fax:706-896-7872
Practice Address - Street 1:110 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HIAWASSEE
Practice Address - State:GA
Practice Address - Zip Code:30546-3408
Practice Address - Country:US
Practice Address - Phone:706-896-2222
Practice Address - Fax:706-896-7872
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029622207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00808585DMedicaid
NC89063MFMedicaid
GAC36352Medicare UPIN
NC89063MFMedicaid
GA93BDMDXMedicare PIN