Provider Demographics
NPI:1255624508
Name:DAVIDSON, MATTHEW LEE (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEE
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 HERITAGE HILLS CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:43090-4624
Mailing Address - Country:US
Mailing Address - Phone:636-239-5252
Mailing Address - Fax:636-239-4499
Practice Address - Street 1:1809 HERITAGE HILLS DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4624
Practice Address - Country:US
Practice Address - Phone:636-239-5252
Practice Address - Fax:636-239-4499
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011012876111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician