Provider Demographics
NPI:1629282496
Name:DAVIS, JUSTIN R (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-2195
Mailing Address - Fax:
Practice Address - Street 1:4015 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1119
Practice Address - Country:US
Practice Address - Phone:806-725-0030
Practice Address - Fax:806-725-0015
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012004798208000000X
KS04-35493208000000X
MS238062080P0204X
TXR49572080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02683804Medicaid
MS424599YJ5DMedicare PIN