Provider Demographics
NPI:1407826209
Name:DAVIES, BRENDA S (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:DAVIES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 E. LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-955-0350
Mailing Address - Fax:208-955-0352
Practice Address - Street 1:315 E ELM ST
Practice Address - Street 2:SUITE 310
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4857
Practice Address - Country:US
Practice Address - Phone:208-454-2035
Practice Address - Fax:208-454-1065
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDG05134207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID15024OtherBLUE CROSS OF IDAHO
OR207527Medicaid
ID000010001161OtherREGENCE BLUE SHIELD OF ID
ID003658200Medicaid
ID000010001161OtherREGENCE BLUE SHIELD OF ID
ID003658200Medicaid