Provider Demographics
NPI:1689788630
Name:DAVIS, DENNON W (MD)
Entity type:Individual
Prefix:
First Name:DENNON
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4105 N WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6296
Mailing Address - Country:US
Mailing Address - Phone:618-244-9495
Mailing Address - Fax:618-244-9497
Practice Address - Street 1:4105 N WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6296
Practice Address - Country:US
Practice Address - Phone:618-244-9495
Practice Address - Fax:618-244-9497
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2024-09-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036099669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
047016OtherHEALTH ALLIANCE
080137051OtherRAILROAD MEDICARE
10019630OtherBCBS
334689OtherHEALTH LINK
10019630OtherBCBS
334689OtherHEALTH LINK
IL214881Medicare Oscar/Certification