Provider Demographics
NPI:1811958804
Name:DAVIS, JAMES R (DO)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1528
Mailing Address - Country:US
Mailing Address - Phone:574-722-2663
Mailing Address - Fax:
Practice Address - Street 1:1101 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1528
Practice Address - Country:US
Practice Address - Phone:574-722-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076015207X00000X
IN02004167A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076015Medicaid
IL3160469577OtherBCBS
IN000000808791OtherANTHEM
IL200019369OtherCOMMERCIAL
IL036076015Medicaid
D14162Medicare UPIN