Provider Demographics
NPI:1871565861
Name:DAVIDSON, KENNETH H (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1415 PORTLAND AVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3038
Mailing Address - Country:US
Mailing Address - Phone:585-426-9278
Mailing Address - Fax:585-338-2738
Practice Address - Street 1:1415 PORTLAND AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3038
Practice Address - Country:US
Practice Address - Phone:585-426-9278
Practice Address - Fax:585-338-2738
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY103663207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
005002871OtherBLUE SHIELD WESTERN NY
P010103663OtherBLUE CHOICE
07341OtherCHOICE CARE
10453OtherGHI
9913OtherBLUE CROSS BLUE SHIELD
Y019296OtherCHAMPUS
NY00450853Medicaid
MD4426OtherPREFERRED CARE
005002871OtherCOMMUNITY BLUE
07341OtherCHOICE CARE
10453OtherGHI
005002871OtherBLUE SHIELD WESTERN NY