1154389906 NPI number — WINSTON BROOKS DAVIS MD

Table of content: WINSTON BROOKS DAVIS MD (NPI 1154389906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154389906 NPI number — WINSTON BROOKS DAVIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
WINSTON
Provider Middle Name:
BROOKS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154389906
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 N SENATE AVE
Provider Second Line Business Mailing Address:
STE EF205
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46202-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-715-6402
Provider Business Mailing Address Fax Number:
317-715-6415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 N SENATE AVE
Provider Second Line Business Practice Location Address:
STE EF205
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-715-6402
Provider Business Practice Location Address Fax Number:
317-715-6415
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  01050878A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 959090AAA6 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00733995 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00800396 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00163349 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00264111 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200128460 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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