Provider Demographics
NPI:1194085902
Name:DAVISSON, JOHN LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LAWRENCE
Last Name:DAVISSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-0485
Mailing Address - Country:US
Mailing Address - Phone:765-521-0890
Mailing Address - Fax:765-521-1555
Practice Address - Street 1:1000 N 16TH ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4319
Practice Address - Country:US
Practice Address - Phone:765-521-0890
Practice Address - Fax:765-521-1555
Is Sole Proprietor?:No
Enumeration Date:2012-05-26
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48216207R00000X
IN01077390A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201377670Medicaid
INP01723965OtherRR MEDICARE
IN266180711Medicare PIN