Provider Demographics
NPI:1053425934
Name:DAVIS, BRYAN C (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:C
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 1:1305 E 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-5201
Mailing Address - Country:US
Mailing Address - Phone:620-221-9500
Mailing Address - Fax:620-221-3700
Practice Address - Street 1:1305 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-5201
Practice Address - Country:US
Practice Address - Phone:620-221-9500
Practice Address - Fax:620-221-3700
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-27652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100327700CMedicaid
KS336640OtherFIRSTGUARD INSURANCE
KS130330OtherBC/BS OF KANSAS
KS110411Medicare ID - Type Unspecified
KS100327700CMedicaid