Provider Demographics
NPI: | 1508811266 |
---|---|
Name: | DAVIS, VICTOR HARDWICK (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | VICTOR |
Middle Name: | HARDWICK |
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: | 919 SOLANO DR NE |
Mailing Address - Street 2: | |
Mailing Address - City: | ALBUQUERQUE |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 87110-7742 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-266-8122 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 919 SOLANO DR NE |
Practice Address - Street 2: | |
Practice Address - City: | ALBUQUERQUE |
Practice Address - State: | NM |
Practice Address - Zip Code: | 87110-7742 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-266-8122 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-05-23 |
Last Update Date: | 2016-02-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | C51844 | 207Q00000X, 208600000X |
NM | 90-214 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208600000X | Allopathic & Osteopathic Physicians | Surgery | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 1508811266 | Medicaid | |
MO | 1508811266 | Medicaid | |
MO | MA2082532 | Medicare PIN | |
CA | 00C518440 | Medicare ID - Type Unspecified |