1588756217 NPI number — DR. BERNETTA WINFRED DAVIS-POOLE OD

Table of content: DR. BERNETTA WINFRED DAVIS-POOLE OD (NPI 1588756217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588756217 NPI number — DR. BERNETTA WINFRED DAVIS-POOLE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS-POOLE
Provider First Name:
BERNETTA
Provider Middle Name:
WINFRED
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVIS
Provider Other First Name:
BERNETTA
Provider Other Middle Name:
WINFRED
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1588756217
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1804 WEST NORTH AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-523-1224
Provider Business Mailing Address Fax Number:
410-728-1804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1804 WEST NORTH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-523-1224
Provider Business Practice Location Address Fax Number:
410-747-6563
Provider Enumeration Date:
09/29/2006

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: 152W00000X , with the licence number:  TA0696 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 790418504 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 790418501 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00870154 . This is a "MEDICARE PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3325172 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com