Provider Demographics
NPI:1346228921
Name:DAVIS, CHARLES ISAAC JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ISAAC
Last Name:DAVIS
Suffix:JR
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 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:913-660-1616
Mailing Address - Fax:913-660-1664
Practice Address - Street 1:1615 PARKER AVE
Practice Address - Street 2:
Practice Address - City:OSAWATOMIE
Practice Address - State:KS
Practice Address - Zip Code:66064-1703
Practice Address - Country:US
Practice Address - Phone:913-660-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018665207RG0300X
KS0429493207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSR28D204Medicare PIN
KS200005190CMedicaid
P00091689Medicare PIN
MOR28D204AMedicare PIN
H87999Medicare UPIN
KS04-29493OtherMEDICAL LICENSE
MO2006018665OtherMEDICAL LICENSE
KS103660Medicare PIN