Provider Demographics
NPI:1447274378
Name:DAVIDSON, IGOR (PHD)
Entity type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 BRIGHTON 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6381
Mailing Address - Country:US
Mailing Address - Phone:718-541-9074
Mailing Address - Fax:
Practice Address - Street 1:2928 BRIGHTON 8TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6381
Practice Address - Country:US
Practice Address - Phone:718-541-9074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016113-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016113-1OtherLICENSE
NY02596463Medicaid
NYVM6301Medicare ID - Type Unspecified