Provider Demographics
NPI:1508064932
Name:DAVENPORT, CRAIG R (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:R
Last Name:DAVENPORT
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 1:320 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1412
Mailing Address - Country:US
Mailing Address - Phone:217-285-6981
Mailing Address - Fax:
Practice Address - Street 1:320 N MADISON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1412
Practice Address - Country:US
Practice Address - Phone:217-285-6981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8205207Q00000X
IA38201207Q00000X
IL036135436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508064932Medicaid
ILF400295269Medicare PIN
IA719260105Medicare PIN