Provider Demographics
NPI:1902854714
Name:DAVIDSON, ANDREW L (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:L
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S TIPPECANOE DR
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1194
Mailing Address - Country:US
Mailing Address - Phone:937-667-1270
Mailing Address - Fax:937-667-7198
Practice Address - Street 1:115 S TIPPECANOE DR
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371-1194
Practice Address - Country:US
Practice Address - Phone:937-667-1270
Practice Address - Fax:937-667-7198
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3901000001OtherDMEPOS
OH22 20152OtherUHC
OH29152503001OtherMEDICAL MUTUAL OF OHIO
OH000000019255OtherANTHEM BC/BS
OH0416035Medicaid
OH22 20152OtherUHC
OH29152503001OtherMEDICAL MUTUAL OF OHIO