Provider Demographics
NPI:1528384195
Name:DAVIS, JARED MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MICHAEL
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 1:1019 ROSEMARY DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1119
Mailing Address - Country:US
Mailing Address - Phone:601-874-1162
Mailing Address - Fax:
Practice Address - Street 1:1019 ROSEMARY DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1119
Practice Address - Country:US
Practice Address - Phone:601-874-1162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2448208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100177660Medicaid