Provider Demographics
NPI:1215217229
Name:JERRY T. DAVIS D.O.,P.A.
Entity Type:Organization
Organization Name:JERRY T. DAVIS D.O.,P.A.
Other - Org Name:LAKE WORTH MINOR EMERGENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-237-8273
Mailing Address - Street 1:6302 JACKSBORO HWY STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3607
Mailing Address - Country:US
Mailing Address - Phone:817-237-8273
Mailing Address - Fax:817-237-0374
Practice Address - Street 1:6302 JACKSBORO HWY STE A
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3607
Practice Address - Country:US
Practice Address - Phone:817-237-8273
Practice Address - Fax:817-237-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty