Provider Demographics
NPI:1497813026
Name:DAVENPORT, MICHELLE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LEE
Last Name:DAVENPORT
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 1:306 PINE HILL RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2920
Mailing Address - Country:US
Mailing Address - Phone:423-542-4189
Mailing Address - Fax:423-542-4181
Practice Address - Street 1:306 PINE HILL RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2920
Practice Address - Country:US
Practice Address - Phone:423-542-4189
Practice Address - Fax:423-542-4181
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36009207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3379172Medicaid
TN3379172Medicare ID - Type Unspecified
TN3379172Medicaid