Provider Demographics
NPI:1225085673
Name:DAVENPORT, JAMES MICHAEL (AUD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-2324
Mailing Address - Country:US
Mailing Address - Phone:860-694-3870
Mailing Address - Fax:
Practice Address - Street 1:1130 BICHARA BLVD
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-7716
Practice Address - Country:US
Practice Address - Phone:352-750-4327
Practice Address - Fax:352-750-2410
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY753231H00000X
MA556231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4515XMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
FLP12961Medicare UPIN