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
StateLicense IDTaxonomies
CAC51844207Q00000X, 208600000X
NM90-214208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1508811266Medicaid
MO1508811266Medicaid
MOMA2082532Medicare PIN
CA00C518440Medicare ID - Type Unspecified