Provider Demographics
NPI:1366448169
Name:DAVIS, J LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:LAWRENCE
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 1:546 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-4154
Mailing Address - Country:US
Mailing Address - Phone:314-721-1574
Mailing Address - Fax:
Practice Address - Street 1:546 WARREN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-4154
Practice Address - Country:US
Practice Address - Phone:314-721-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020002292207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201851623Medicaid
MO018012206Medicare ID - Type UnspecifiedAREA 1
MO201851623Medicaid