Provider Demographics
NPI:1699882001
Name:DAVIS, STEPHEN E (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
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 1:415 JEFFERSON ST N
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1264
Mailing Address - Country:US
Mailing Address - Phone:218-631-3510
Mailing Address - Fax:
Practice Address - Street 1:4 DEERWOOD AVE NW
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1253
Practice Address - Country:US
Practice Address - Phone:218-631-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN867203200Medicaid
MN867203200Medicaid