Provider Demographics
NPI:1720074883
Name:DAVENPORT, GARY B (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:B
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26280-0247
Mailing Address - Country:US
Mailing Address - Phone:304-335-2050
Mailing Address - Fax:304-335-6158
Practice Address - Street 1:US ROUTES 219 & 250
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WV
Practice Address - Zip Code:26280-0000
Practice Address - Country:US
Practice Address - Phone:304-335-2050
Practice Address - Fax:304-335-6158
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3004232000Medicaid
DA2024461Medicare ID - Type Unspecified
WV3004232000Medicaid
DA4218592Medicare PIN