Provider Demographics
NPI:1568469955
Name:DAVIS, BERT I (MD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:I
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1210 MEDICAL ARTS BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3461
Mailing Address - Country:US
Mailing Address - Phone:765-644-1271
Mailing Address - Fax:765-298-4999
Practice Address - Street 1:1210 MEDICAL ARTS BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3461
Practice Address - Country:US
Practice Address - Phone:765-644-1271
Practice Address - Fax:765-298-4999
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC25282Medicare UPIN
IN166080Medicare ID - Type Unspecified