Provider Demographics
NPI:1568406387
Name:DAVIS, KENT CHARLES (MD)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:CHARLES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:411 3RD ST N STE 4
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-0003
Mailing Address - Country:US
Mailing Address - Phone:320-253-4120
Mailing Address - Fax:320-253-4179
Practice Address - Street 1:411 3RD ST N
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1177
Practice Address - Country:US
Practice Address - Phone:320-253-4120
Practice Address - Fax:320-253-4179
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN317592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP25413OtherHEALTH PARTNERS
8L641DAOtherBCBS
110587C851OtherUCARE
1520376OtherMEDICA
MN561597600Medicaid
92224583001OtherPREFERRED ONE
92224583001OtherPREFERRED ONE
E38745Medicare UPIN