Provider Demographics
NPI:1265479364
Name:DAVIS, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:201 S OCEAN GRANDE DR
Mailing Address - Street 2:SUITE PH4
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6515
Mailing Address - Country:US
Mailing Address - Phone:214-783-2563
Mailing Address - Fax:214-820-8168
Practice Address - Street 1:3410 WORTH STREET
Practice Address - Street 2:SUITE 860
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-820-8500
Practice Address - Fax:214-820-8168
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2014-07-03
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Provider Licenses
StateLicense IDTaxonomies
TXL4323207RG0100X, 207RI0008X, 207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157390901Medicaid
TX157390902Medicaid
TX8G0555OtherBCBS
TX100016785Medicare PIN
TX8G0555OtherBCBS
TX157390902Medicaid
TX157390901Medicaid