Provider Demographics
NPI:1326047119
Name:DAVIS, KEVIN W (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1455
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-1455
Mailing Address - Country:US
Mailing Address - Phone:615-382-8056
Mailing Address - Fax:615-382-8056
Practice Address - Street 1:312 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3963
Practice Address - Country:US
Practice Address - Phone:615-384-3112
Practice Address - Fax:615-382-7332
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00302213E00000X
KY302213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4179406OtherBLUE CROSS BLUE SHIELD TENNESSEE
KYP00419400OtherRAILROAD MEDICARE
KY90004391OtherMEDICAID DME
KY80900319Medicaid
TN3736461Medicaid
KY80000565Medicaid
KYDF9516OtherRAILROAD MEDICARE
TN3353857Medicaid
KY90004391OtherMEDICAID DME
TN3353857Medicaid
TN33538552Medicare PIN
TN3736461Medicare PIN
KY80000565Medicaid