Provider Demographics
NPI:1225030091
Name:DAVIS, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
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 1:1627 SEYMOUR DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-3428
Mailing Address - Country:US
Mailing Address - Phone:434-517-0611
Mailing Address - Fax:434-572-6675
Practice Address - Street 1:1627 SEYMOUR DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-3428
Practice Address - Country:US
Practice Address - Phone:434-517-0611
Practice Address - Fax:434-572-6675
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110164769OtherRR/MED
241669OtherBV/BS
VA605634-2Medicaid
E69531Medicare UPIN
VA605634-2Medicaid