Provider Demographics
NPI:1053435362
Name:DONALD D DAVENPORT JR D O P A
Entity type:Organization
Organization Name:DONALD D DAVENPORT JR D O P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:432-580-8330
Mailing Address - Street 1:540 W 5TH ST STE 470
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5070
Mailing Address - Country:US
Mailing Address - Phone:432-580-8330
Mailing Address - Fax:432-580-8333
Practice Address - Street 1:540 W 5TH ST STE 470
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5070
Practice Address - Country:US
Practice Address - Phone:432-580-8330
Practice Address - Fax:432-580-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0118208600000X, 2086S0102X, 2086S0120X, 2086S0127X, 2086X0206X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0017HGOtherGROUP # BCBS
TX0017HGOtherGROUP # BCBS
TX00455QMedicare ID - Type UnspecifiedMCARE