Provider Demographics
NPI:1588269757
Name:DAVIDSON, ROMAN JACKSON
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:JACKSON
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-2047
Mailing Address - Country:US
Mailing Address - Phone:304-309-5069
Mailing Address - Fax:
Practice Address - Street 1:1202 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951-2047
Practice Address - Country:US
Practice Address - Phone:304-309-5069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant