Provider Demographics
NPI:1861433997
Name:DAVIDSON, LESLY S (MD)
Entity type:Individual
Prefix:
First Name:LESLY
Middle Name:S
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 VON KOLNITZ RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3772
Mailing Address - Country:US
Mailing Address - Phone:843-216-3376
Mailing Address - Fax:843-216-3242
Practice Address - Street 1:901 VON KOLNITZ RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3772
Practice Address - Country:US
Practice Address - Phone:843-216-3376
Practice Address - Fax:843-216-3242
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17272174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC172725Medicaid
SCG650400281Medicare ID - Type Unspecified
SC172725Medicaid