Provider Demographics
NPI:1174551428
Name:DAVIDSON, ADELIA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:ADELIA
Middle Name:MARIE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ADELIA
Other - Middle Name:MARIE
Other - Last Name:MANSFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 DELWOOD PL
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4875
Mailing Address - Country:US
Mailing Address - Phone:970-259-1875
Mailing Address - Fax:
Practice Address - Street 1:575 RIVERGATE
Practice Address - Street 2:SUITE 210
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7487
Practice Address - Country:US
Practice Address - Phone:970-247-0042
Practice Address - Fax:970-259-8837
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
68587687OtherTPIN
10404779OtherCAQH
CO01256205Medicaid
COCN7746Medicare PIN
E23625Medicare UPIN