Provider Demographics
NPI:1093796104
Name:DAVIS, JOHN K (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:K
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 SATTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-7905
Mailing Address - Country:US
Mailing Address - Phone:208-238-0235
Mailing Address - Fax:
Practice Address - Street 1:2735 SILVER CREEK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7924
Practice Address - Country:US
Practice Address - Phone:928-763-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3192207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ392241Medicaid
AZAZ0728670OtherBLUECROSS/BLUESHIELD GRP
AZAW1436OtherHEALTHNET GROUP
AZ39-87220OtherEVERCARE GROUP
AZAZ0728670OtherBLUECROSS/BLUESHIELD GRP
AZZ108330Medicare PIN