1639259450 NPI number — DR. GREGORY W DAVIS MD

Table of content: DR. GREGORY W DAVIS MD (NPI 1639259450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639259450 NPI number — DR. GREGORY W DAVIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
GREGORY
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
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:
1639259450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 S 56TH ST, SUITE 110
Provider Second Line Business Mailing Address:
P O BOX 11880
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72917-1880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-452-1581
Provider Business Mailing Address Fax Number:
479-452-2148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 S 56TH ST,
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-3710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-452-1581
Provider Business Practice Location Address Fax Number:
479-452-2148
Provider Enumeration Date:
10/16/2006

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: 207L00000X , with the licence number:  N8315 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 122330001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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