Provider Demographics
NPI:1871047639
Name:DAVIDSON, ANDREW JEREMIAH (STUDENT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JEREMIAH
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6232 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2532
Mailing Address - Country:US
Mailing Address - Phone:214-668-9607
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:214-668-9607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23588888390200000X
TX235888881710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman