Provider Demographics
NPI:1518981539
Name:DAVENPORT, DAVID ROSS JR (PA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ROSS
Last Name:DAVENPORT
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 WYCOMBE DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3862
Mailing Address - Country:US
Mailing Address - Phone:302-678-2455
Mailing Address - Fax:
Practice Address - Street 1:1275 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6927
Practice Address - Country:US
Practice Address - Phone:302-678-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000498363A00000X
DEC5-0000498207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEMD1424617OtherDEA
DE137220Y0DMedicare PIN