Provider Demographics
NPI:1598775462
Name:DAVIS, KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 BROADWAY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-3225
Mailing Address - Country:US
Mailing Address - Phone:212-334-1155
Mailing Address - Fax:212-334-4395
Practice Address - Street 1:568 BROADWAY
Practice Address - Street 2:SUITE 303
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3225
Practice Address - Country:US
Practice Address - Phone:212-334-1155
Practice Address - Fax:212-334-4395
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177164207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39H701Medicare ID - Type UnspecifiedPROVIDER ID