Provider Demographics
NPI:1134187990
Name:DAVISON, MARK ELLISON (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLISON
Last Name:DAVISON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S ALLEN ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4849
Mailing Address - Country:US
Mailing Address - Phone:814-237-2204
Mailing Address - Fax:814-237-9611
Practice Address - Street 1:315 S ALLEN ST
Practice Address - Street 2:SUITE 118
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4849
Practice Address - Country:US
Practice Address - Phone:814-237-2204
Practice Address - Fax:814-237-9611
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002529L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADA452998Medicare ID - Type Unspecified
PAT72946Medicare UPIN