Provider Demographics
NPI:1619009859
Name:DAVIS, BRENT WADE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WADE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-0207
Mailing Address - Country:US
Mailing Address - Phone:405-786-2248
Mailing Address - Fax:405-786-2006
Practice Address - Street 1:315 W. 9 STREET
Practice Address - Street 2:
Practice Address - City:WELEETKA
Practice Address - State:OK
Practice Address - Zip Code:74880-0337
Practice Address - Country:US
Practice Address - Phone:405-786-2248
Practice Address - Fax:405-786-2006
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100743630AMedicaid
OK100743630BMedicaid
OK100743630AMedicaid