Provider Demographics
NPI:1003457680
Name:DAVIS, KEJUAN DESHAWN
Entity Type:Individual
Prefix:
First Name:KEJUAN
Middle Name:DESHAWN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17583 HARTWELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2639
Mailing Address - Country:US
Mailing Address - Phone:313-286-6790
Mailing Address - Fax:
Practice Address - Street 1:7401 PARKLAND
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1015
Practice Address - Country:US
Practice Address - Phone:313-914-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver