Provider Demographics
NPI:1144226408
Name:DAVIS, LEON D (MD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:D
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 1:245 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6333
Mailing Address - Country:US
Mailing Address - Phone:910-353-4333
Mailing Address - Fax:910-353-6529
Practice Address - Street 1:245 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6333
Practice Address - Country:US
Practice Address - Phone:910-353-4333
Practice Address - Fax:910-353-6529
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21336174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927452Medicaid
NC2218250Medicare ID - Type Unspecified
NC8927452Medicaid