Provider Demographics
NPI:1386637221
Name:DAVIS, PAUL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WAYNE
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:PO BOX 20940
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71612-0940
Mailing Address - Country:US
Mailing Address - Phone:870-879-6791
Mailing Address - Fax:870-879-4476
Practice Address - Street 1:7400 DOLLARWAY RD
Practice Address - Street 2:STE A
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-3025
Practice Address - Country:US
Practice Address - Phone:870-879-6791
Practice Address - Fax:870-879-4476
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103077001Medicaid
110066191OtherMEDICARE-ID UNSPECIFIED
AR103077001Medicaid
C68133Medicare UPIN