Provider Demographics
NPI:1568480176
Name:DAVIS, KEEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEEVIN
Middle Name:R
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 1:3460 DAVIS LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45237-2402
Mailing Address - Country:US
Mailing Address - Phone:513-482-9291
Mailing Address - Fax:513-351-1547
Practice Address - Street 1:3328 PRINCETON ROAD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011
Practice Address - Country:US
Practice Address - Phone:513-887-9400
Practice Address - Fax:513-887-7512
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046494208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0811536Medicaid
OHH073500OtherMEDICARE PTAN
OH000000590417OtherANTHEM
OHH073500OtherMEDICARE PTAN