Provider Demographics
NPI:1316112089
Name:DAVIS, BARRY D (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:D
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 1:3461 FAIRLANE FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8752
Mailing Address - Country:US
Mailing Address - Phone:561-766-1300
Mailing Address - Fax:561-693-0539
Practice Address - Street 1:241 SE 1ST ST
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-3501
Practice Address - Country:US
Practice Address - Phone:561-707-9149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123475208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1316112089Medicaid
SCNC2668Medicaid
SCNC2668Medicaid