Provider Demographics
NPI:1366470833
Name:DAVIS, ROBERT W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-345-5250
Practice Address - Fax:208-345-2364
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3919207Q00000X
IDM3919207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20002345Medicare PIN