Provider Demographics
NPI:1104913631
Name:DAVIDSON, MARK DOUGLAS (HIS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 50TH STREET
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414
Mailing Address - Country:US
Mailing Address - Phone:806-799-8950
Mailing Address - Fax:806-792-9404
Practice Address - Street 1:1600 COULTER
Practice Address - Street 2:BLDG A STE 105
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106
Practice Address - Country:US
Practice Address - Phone:806-352-2321
Practice Address - Fax:806-355-8941
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50631237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist