Provider Demographics
NPI:1306887674
Name:DAVIS, GREGG E (MD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:E
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 1:204 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-2114
Mailing Address - Country:US
Mailing Address - Phone:815-879-3212
Mailing Address - Fax:815-879-8602
Practice Address - Street 1:204 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2114
Practice Address - Country:US
Practice Address - Phone:815-879-3212
Practice Address - Fax:815-879-8602
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36058885207P00000X
IL036-058885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL587120Medicare ID - Type Unspecified
ILD14677Medicare UPIN