Provider Demographics
NPI:1699710434
Name:RICHARD D DAVENPORT MD AND ASSOCIATES, SC
Entity type:Organization
Organization Name:RICHARD D DAVENPORT MD AND ASSOCIATES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DRAKE
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-328-8762
Mailing Address - Street 1:3033 W LAYTON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2628
Mailing Address - Country:US
Mailing Address - Phone:414-279-5579
Mailing Address - Fax:414-249-3299
Practice Address - Street 1:3033 W LAYTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2628
Practice Address - Country:US
Practice Address - Phone:414-279-5579
Practice Address - Fax:414-249-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19876207W00000X
WI207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21300200Medicaid
WICC8272OtherPALMETTO GBA-RAILROAD
WI21300200Medicaid
WI0480330001Medicare NSC