Provider Demographics
NPI:1427048404
Name:DAVIS, TAKEISHA CHARLES (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:TAKEISHA
Middle Name:CHARLES
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1434 TIGER DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4337
Mailing Address - Country:US
Mailing Address - Phone:985-447-0916
Mailing Address - Fax:985-447-0920
Practice Address - Street 1:1434 TIGER DR
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4337
Practice Address - Country:US
Practice Address - Phone:985-447-0916
Practice Address - Fax:985-447-0920
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200311208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA64663Medicaid
LA64663Medicaid