Provider Demographics
NPI:1053302240
Name:DAVIS, DAVID P (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:
Practice Address - Street 1:890 E RIDGELAWN RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62442-2551
Practice Address - Country:US
Practice Address - Phone:217-382-4191
Practice Address - Fax:217-382-4248
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039458A207Q00000X
IL036086811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL006686OtherHEALTH ALLIANCE
IL311661293OtherHEALTH LINK
IL0004400750OtherAETNA
IL311661293OtherPERSONAL CARE
IL311661293001Medicaid
IN000000079566OtherANTHEM BLUE CROSS
IL01225376OtherBLUE CROSS BLUE SHIELD
IL006686OtherHEALTH ALLIANCE
IL143935Medicare ID - Type UnspecifiedRURAL HEATLH MEDICARE
E46673Medicare UPIN