Provider Demographics
NPI:1215908991
Name:DAVIDSON, DIANE MEG (MD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MEG
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 GOLD STAR HWY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-445-8020
Mailing Address - Fax:860-445-1665
Practice Address - Street 1:491 GOLD STAR HWY
Practice Address - Street 2:SUITE 310
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-445-8020
Practice Address - Fax:860-445-1665
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT025536207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D95243Medicare UPIN
CT070000Medicare ID - Type Unspecified