Provider Demographics
NPI:1346484581
Name:DAVENPORT, DEREK JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JOSEPH
Last Name:DAVENPORT
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 1:1055 N 500 W
Mailing Address - Street 2:ATTN. CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:4095 E PONY EXPRESS PKWY STE 1
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5531
Practice Address - Country:US
Practice Address - Phone:801-429-8037
Practice Address - Fax:801-753-7476
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11327523-1205207R00000X, 208000000X
ORMD162235207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1346484581OtherNPI
OR500659989Medicaid
R170930Medicare PIN