Provider Demographics
NPI:1336145309
Name:DAVIS, MARK E (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 YOUNGSTOWN KINGSVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44473-9601
Mailing Address - Country:US
Mailing Address - Phone:800-471-8592
Mailing Address - Fax:330-758-5121
Practice Address - Street 1:341 YOUNGSTOWN KINGSVILLE RD SE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:OH
Practice Address - Zip Code:44473-9601
Practice Address - Country:US
Practice Address - Phone:800-471-8592
Practice Address - Fax:330-758-5121
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0797857Medicaid
OH2056260Medicaid
OH0667382Medicare PIN
OH0667384Medicare PIN
OH2056260Medicaid
OH0667381Medicare PIN