Provider Demographics
NPI:1508885047
Name:DAVIS, MARK B (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 N WINDSONG DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-772-5320
Mailing Address - Fax:928-772-5319
Practice Address - Street 1:3237 N WINDSONG DRIVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-772-5320
Practice Address - Fax:928-772-5319
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10024207X00000X
AZ4810174400000X, 208D00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27845480-0Medicaid
FLP00459927OtherRR MEDICARE
FLAF034ZMedicare PIN
AZZ121349Medicare PIN
AZZ122510Medicare PIN