Provider Demographics
NPI:1023577194
Name:DAVIS, CRAIG R
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:R
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 1:1344 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1703
Mailing Address - Country:US
Mailing Address - Phone:330-742-2595
Mailing Address - Fax:216-591-0223
Practice Address - Street 1:1344 5TH AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1703
Practice Address - Country:US
Practice Address - Phone:330-742-2595
Practice Address - Fax:216-591-0223
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2488400Medicaid