Provider Demographics
NPI:1508204132
Name:DAVIS, IDALIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:IDALIE
Middle Name:
Last Name:DAVIS
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 1:84 SCHAEFER ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-1024
Mailing Address - Country:US
Mailing Address - Phone:917-805-5594
Mailing Address - Fax:
Practice Address - Street 1:84 SCHAEFER ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-1024
Practice Address - Country:US
Practice Address - Phone:917-805-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor