Provider Demographics
NPI:1356449276
Name:DAVIS, MARK R II
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:DAVIS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 N ROCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-1139
Mailing Address - Country:US
Mailing Address - Phone:262-363-1810
Mailing Address - Fax:
Practice Address - Street 1:930 IL ROUTE 22
Practice Address - Street 2:
Practice Address - City:FOX RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60021-1905
Practice Address - Country:US
Practice Address - Phone:847-516-1688
Practice Address - Fax:847-516-9269
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009126111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL598280Medicare ID - Type Unspecified