Provider Demographics
NPI:1477525632
Name:DAVENPORT, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3601 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8151
Mailing Address - Country:US
Mailing Address - Phone:231-946-1120
Mailing Address - Fax:231-946-8943
Practice Address - Street 1:3601 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8151
Practice Address - Country:US
Practice Address - Phone:231-946-1120
Practice Address - Fax:231-946-8943
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477525632Medicaid
MI080B86010OtherBCBSM
MIB44197Medicare UPIN
MI1477525632Medicare PIN
MA080B86010OtherBLUE SHIELD