Provider Demographics
NPI:1003935453
Name:DAVENPORT, JERRY M (D O)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9223 STONE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-2698
Mailing Address - Country:US
Mailing Address - Phone:801-944-1335
Mailing Address - Fax:801-944-1335
Practice Address - Street 1:306 W 5TH AVE
Practice Address - Street 2:NORTON SOUND HEALTH COOPERATION
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-3214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine