Provider Demographics
NPI:1497728562
Name:DAVIS, THOMAS E (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
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 1:9513 HIGHWAY 100
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MO
Mailing Address - Zip Code:63068-1300
Mailing Address - Country:US
Mailing Address - Phone:573-237-6100
Mailing Address - Fax:573-437-8664
Practice Address - Street 1:9513 HIGHWAY 100
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MO
Practice Address - Zip Code:63068-1300
Practice Address - Country:US
Practice Address - Phone:573-237-6100
Practice Address - Fax:573-437-8664
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01134571OtherRAILROAD MEDICARE
MO206946600Medicaid
080121830OtherRAILROAD MEDICARE
MOP01134571OtherRAILROAD MEDICARE
MO152810057Medicare PIN
MO206946600Medicaid