Provider Demographics
NPI:1679756027
Name:DAVIS, BJ (DO)
Entity type:Individual
Prefix:
First Name:BJ
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3804 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1081
Mailing Address - Country:US
Mailing Address - Phone:505-883-8099
Mailing Address - Fax:505-883-8060
Practice Address - Street 1:3804 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1081
Practice Address - Country:US
Practice Address - Phone:505-883-8099
Practice Address - Fax:505-883-8060
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMA40958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2300559OtherMEDICARE PTAN
NM41723Medicaid
NM41723Medicaid