Provider Demographics
NPI:1003806464
Name:DAVANG, JEFFREY FRED (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:FRED
Last Name:DAVANG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3719 COUNTY ROAD 131
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-8535
Mailing Address - Country:US
Mailing Address - Phone:713-252-5200
Mailing Address - Fax:979-563-1693
Practice Address - Street 1:1501 E MOCKINGBIRD LN
Practice Address - Street 2:101
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2155
Practice Address - Country:US
Practice Address - Phone:361-573-2481
Practice Address - Fax:361-576-2434
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX642422207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83842UOtherBLUE CROSS/BLUE SHIELD
TX052983OtherRECERTIFICATION
TX151044802Medicaid
TXP00090293OtherRAILROAD MEDICARE
TXP00090293OtherRAILROAD MEDICARE
TXTXB148676Medicare PIN
TXP00090293OtherRAILROAD MEDICARE