Provider Demographics
NPI:1043288269
Name:DAVIS, THOMAS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JAMES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56087-1212
Mailing Address - Country:US
Mailing Address - Phone:507-227-5517
Mailing Address - Fax:
Practice Address - Street 1:404 W CENTRAL ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MN
Practice Address - Zip Code:56087
Practice Address - Country:US
Practice Address - Phone:507-227-5517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43290208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN488865100Medicaid
G17387Medicare UPIN
MN488865100Medicaid