Provider Demographics
NPI:1578790473
Name:DAVIS, BRYAN MARK (DO)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:MARK
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O BOX 1205
Mailing Address - Street 2:
Mailing Address - City:CENTER POINT
Mailing Address - State:TX
Mailing Address - Zip Code:78010
Mailing Address - Country:US
Mailing Address - Phone:830-285-7881
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:230 MESA VERDE DR.
Practice Address - Street 2:
Practice Address - City:CENTER POINT
Practice Address - State:TX
Practice Address - Zip Code:78010
Practice Address - Country:US
Practice Address - Phone:830-634-2212
Practice Address - Fax:830-634-7820
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5634207Q00000X
TXN7611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ620864Medicaid
TXTXB120327Medicare PIN