Provider Demographics
NPI:1396010096
Name:SAMUEL H. DAVIS MD PA
Entity Type:Organization
Organization Name:SAMUEL H. DAVIS MD PA
Other - Org Name:CHILD PLUS PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/SENIOR PARTNER-ON-SITE-MEDICAL
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DELAWTER
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:940-484-6500
Mailing Address - Street 1:3205 MEDPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-6932
Mailing Address - Country:US
Mailing Address - Phone:940-484-6500
Mailing Address - Fax:800-481-0150
Practice Address - Street 1:604 E. BAILEY BOSWELL
Practice Address - Street 2:SUITE 140
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76131
Practice Address - Country:US
Practice Address - Phone:817-484-6610
Practice Address - Fax:817-423-7476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1396010096OtherTRICARE