Provider Demographics
NPI:1699771584
Name:DAVIS, RICHARD GARY (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GARY
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 1:825 E GATE BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2136
Mailing Address - Country:US
Mailing Address - Phone:516-804-5200
Mailing Address - Fax:516-240-6540
Practice Address - Street 1:1700 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-5614
Practice Address - Country:US
Practice Address - Phone:631-462-2020
Practice Address - Fax:631-462-2227
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170977174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01073858Medicaid
NY180042102OtherRAILROAD MEDICARE
NY180042102OtherRAILROAD MEDICARE
NYE15503Medicare UPIN
NY79F301Medicare ID - Type UnspecifiedMEDICARE ID #