Provider Demographics
NPI:1902245848
Name:DAVIDSON, EVAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:M
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:9880 ANGIES WAY STE 420
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241
Practice Address - Country:US
Practice Address - Phone:502-394-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3662207Q00000X
KY51086207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty