Provider Demographics
NPI:1649230525
Name:DAVENPORT, LEAMON L (DO)
Entity Type:Individual
Prefix:MR
First Name:LEAMON
Middle Name:L
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:30 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3955
Mailing Address - Country:US
Mailing Address - Phone:610-619-7410
Mailing Address - Fax:610-876-8483
Practice Address - Street 1:30 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013-3955
Practice Address - Country:US
Practice Address - Phone:610-619-7410
Practice Address - Fax:610-876-8483
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB08546500208000000X, 208M00000X
NMA123303208000000X
PAOS017399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43670083Medicaid
AZ807919Medicaid