Provider Demographics
NPI:1326154147
Name:DAVIS, MARK HUDSON (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HUDSON
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 1:225 DUPERIER AVE
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-2417
Mailing Address - Country:US
Mailing Address - Phone:337-519-3353
Mailing Address - Fax:
Practice Address - Street 1:10655 STEEPLETOP DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4222
Practice Address - Country:US
Practice Address - Phone:281-517-9102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.12888R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1549827Medicaid
LA5E432Medicare PIN
LA5E432Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
LA1549827Medicaid