Provider Demographics
NPI:1376626416
Name:DAVIS, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
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 1:109 NORTH 29TH STREET-SUITE 1
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701
Mailing Address - Country:US
Mailing Address - Phone:402-644-4600
Mailing Address - Fax:402-644-3430
Practice Address - Street 1:109 NORTH 29TH STREET-SUITE 1
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701
Practice Address - Country:US
Practice Address - Phone:402-644-4600
Practice Address - Fax:402-644-3430
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17496174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025059200Medicaid
NE10025059200Medicaid
NE269219Medicare ID - Type Unspecified