Provider Demographics
NPI:1366475576
Name:DAVIS, TAMMY JILL (MD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JILL
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:DAVIS
Other - Last Name:BAUDOIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-8032
Mailing Address - Fax:318-675-8775
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-8032
Practice Address - Fax:318-675-8775
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07634R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1386596Medicaid
LA07634RMedicare UPIN
LA5J880F600Medicare PIN