Provider Demographics
NPI:1427699735
Name:DAVIDSON, AUSTIN (LAC)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 DARLING AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1076
Practice Address - Country:US
Practice Address - Phone:908-688-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00141400171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty