Provider Demographics
NPI:1982608964
Name:DAVENPORT, DONALD D JR (DO)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:D
Last Name:DAVENPORT
Suffix:JR
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 1:540 W 5TH ST STE 470
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5070
Mailing Address - Country:US
Mailing Address - Phone:432-580-8330
Mailing Address - Fax:432-580-8333
Practice Address - Street 1:540 W 5TH ST
Practice Address - Street 2:STE 470
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5070
Practice Address - Country:US
Practice Address - Phone:432-580-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2007-10-11
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TXL0118208600000X, 2086S0102X, 2086S0120X, 2086S0127X, 208C00000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0641OtherBLUE CROSS PRIVIDER #
TX00455QMedicare ID - Type UnspecifiedMEDICARE
TX8F0641OtherBLUE CROSS PRIVIDER #