Provider Demographics
NPI:1407896947
Name:DAVIS, TIMOTHY MARK (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MARK
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 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7659
Mailing Address - Country:US
Mailing Address - Phone:276-258-1800
Mailing Address - Fax:276-619-2497
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7659
Practice Address - Country:US
Practice Address - Phone:276-258-1800
Practice Address - Fax:276-619-2497
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33807207RH0003X
VA010241203207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010413133Medicaid
NC8927879Medicaid
NCC78314Medicare UPIN
VA010413133Medicaid
VAC78314Medicare UPIN
VA013164C70Medicare PIN