Basic Information
| Provider Information | |||||||||
| NPI: | 1568495398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 1205 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146928262 | ||||||||
| FaxNumber: | 2146964190 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W COLLEGE ST | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148266021 | ||||||||
| FaxNumber: | 2148539415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | L0783 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 164661403 | 05 | TX | MEDICAID | 164661402 | 05 | TX | MEDICAID | 164661403 | 01 | TX | RRMCR | OTHER | 164661404 | 05 | TX | MEDICAID |