Provider Demographics
NPI:1003149493
Name:RICHARD K DAVIS MD PLLC PA
Entity Type:Organization
Organization Name:RICHARD K DAVIS MD PLLC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:870-725-3471
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:SMACKOVER
Mailing Address - State:AR
Mailing Address - Zip Code:71762-0069
Mailing Address - Country:US
Mailing Address - Phone:870-725-3471
Mailing Address - Fax:870-725-3215
Practice Address - Street 1:1400 PERSHING HWY
Practice Address - Street 2:
Practice Address - City:SMACKOVER
Practice Address - State:AR
Practice Address - Zip Code:71762-2300
Practice Address - Country:US
Practice Address - Phone:870-725-3471
Practice Address - Fax:870-725-3215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
51303OtherBCBS
AR106187001Medicaid
AR106187001Medicaid
ARD04486Medicare UPIN