Provider Demographics
NPI:1336171925
Name:DAVENPORT, JEFFREY CRAIG (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CRAIG
Last Name:DAVENPORT
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 1:3815 S BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5479
Mailing Address - Country:US
Mailing Address - Phone:405-285-7568
Mailing Address - Fax:405-285-7634
Practice Address - Street 1:3815 S BOULEVARD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5479
Practice Address - Country:US
Practice Address - Phone:405-285-7568
Practice Address - Fax:405-285-7634
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200089300AMedicaid
OK200089300AMedicaid
OKOK700724Medicare PIN