Provider Demographics
NPI:1629027313
Name:DAVIS, BRANDY ALEXIS (MD)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:ALEXIS
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 1:904 HOLIDAY DR
Mailing Address - Street 2:SUITE 406
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-9183
Mailing Address - Country:US
Mailing Address - Phone:870-494-4000
Mailing Address - Fax:870-494-4033
Practice Address - Street 1:904 HOLIDAY DR
Practice Address - Street 2:SUITE 406
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-9183
Practice Address - Country:US
Practice Address - Phone:870-494-4000
Practice Address - Fax:870-494-4033
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4147207Q00000X
TN37651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
03100016100OtherQUALCHOICE OF ARKANSAS
AR5N098OtherBLUE CROSS BLUE SHIELD
AR150076001Medicaid
AR5N098Medicare ID - Type Unspecified
AR150076001Medicaid
H88990Medicare UPIN