Provider Demographics
NPI:1205821600
Name:DAVIS, BRUCE ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ANTHONY
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 1:9905 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2907
Mailing Address - Country:US
Mailing Address - Phone:502-425-5166
Mailing Address - Fax:502-327-0526
Practice Address - Street 1:9905 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2907
Practice Address - Country:US
Practice Address - Phone:502-425-5166
Practice Address - Fax:502-327-0526
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY181902080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64181902Medicaid
KY64181902Medicaid