Provider Demographics
NPI:1568666121
Name:DAVIS, JUSTIN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MARK
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:PO BOX 248875
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73124-8875
Mailing Address - Country:US
Mailing Address - Phone:918-392-2944
Mailing Address - Fax:918-664-2521
Practice Address - Street 1:5501 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2074
Practice Address - Country:US
Practice Address - Phone:405-604-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0026250207L00000X
OK27437207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200286500AMedicaid
3849060601OtherMYUTMB 3849060601-COMMERCIAL NUMBER
OKOKA100643Medicare PIN