Provider Demographics
NPI:1174511919
Name:DAVENPORT, DAVID GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GREGORY
Last Name:DAVENPORT
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:PO BOX 140349
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99514-0349
Mailing Address - Country:US
Mailing Address - Phone:907-792-7920
Mailing Address - Fax:907-792-7901
Practice Address - Street 1:2751 DEBARR RD
Practice Address - Street 2:SUITE 390
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2952
Practice Address - Country:US
Practice Address - Phone:907-792-7920
Practice Address - Fax:907-792-7901
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE18172085R0202X
AK60382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141610001Medicaid
AR141610001Medicaid
AR5L665Medicare ID - Type Unspecified