Provider Demographics
NPI:1558858761
Name:DAVIS, ELIZABETH MARY (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:MMC 284
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-5454
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE STREET SE
Practice Address - Street 2:MMC 284
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN67352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty