Provider Demographics
NPI:1083618615
Name:DAVIS, MARK L (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-757-2101
Mailing Address - Fax:
Practice Address - Street 1:1739 E BEVERLY AVE STE 102
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-681-8693
Practice Address - Fax:928-681-8694
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012747207X00000X
AZ007480207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200C313650OtherBCBS MI
MI4837808Medicaid
MI200C31650OtherBLUECARE NETWORK
MI300040412OtherTRICARE
MI200000001852OtherPHYSICIANS HEALTH PLAN
MI2053302675OtherBLUE SHIELD
MI2053302675OtherBLUE SHIELD
MI200C31650OtherBLUECARE NETWORK
MI0P12160Medicare ID - Type UnspecifiedMEDICARE