Provider Demographics
NPI:1306954144
Name:DAVIS, JAMES R (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
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 1:19654 PROMISE RD
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-9179
Mailing Address - Country:US
Mailing Address - Phone:317-430-7636
Mailing Address - Fax:
Practice Address - Street 1:19654 PROMISE RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-9179
Practice Address - Country:US
Practice Address - Phone:317-430-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY334982084B0040X
IN01024043A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100360240Medicaid
KY64343981Medicaid
IN000000272841OtherANTHEM
ININ2746Medicare PIN
KY64343981Medicaid
IN100360240Medicaid