Provider Demographics
NPI:1639152978
Name:DAVIS, KIRK R (DO)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:R
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 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623
Mailing Address - Country:US
Mailing Address - Phone:419-473-9500
Mailing Address - Fax:419-473-9501
Practice Address - Street 1:4126 N HOLLAND SYLVANIA ROAD
Practice Address - Street 2:100
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623
Practice Address - Country:US
Practice Address - Phone:419-473-9500
Practice Address - Fax:419-473-9501
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-005964207XX0005X
OH34005964207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH200044047OtherRAILROAD MEDICARE
OH2139340Medicaid
OH0883607Medicare PIN
OH2139340Medicaid