Provider Demographics
NPI:1609862291
Name:DAVIS, GREGORY J (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 SHAKER BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3873
Mailing Address - Country:US
Mailing Address - Phone:216-791-0017
Mailing Address - Fax:216-791-0021
Practice Address - Street 1:11201 SHAKER BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3873
Practice Address - Country:US
Practice Address - Phone:440-842-5555
Practice Address - Fax:440-842-5556
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007492D207R00000X
OH34007492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2249409Medicaid
OHH44619Medicare UPIN
OH4057421Medicare ID - Type Unspecified
OH2249409Medicaid