Provider Demographics
NPI:1659376952
Name:DAVIS, WILLIE BOB (ME)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:BOB
Last Name:DAVIS
Suffix:
Gender:M
Credentials:ME
Other - Prefix:
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Mailing Address - Street 1:5800 FOXRIDGE DR
Mailing Address - Street 2:STE 240
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-2338
Mailing Address - Country:US
Mailing Address - Phone:913-261-3153
Mailing Address - Fax:913-262-3295
Practice Address - Street 1:20333 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5350
Practice Address - Country:US
Practice Address - Phone:913-791-4408
Practice Address - Fax:913-791-4438
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KSKS 04-17213207Q00000X
MOMO R5059207Q00000X
MOR50592085R0202X
KS04-17213208D00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201018322Medicaid
KS10001780CMedicaid
KS10001780CMedicaid
MOJ960640Medicare PIN
MO201018322Medicaid
D93753Medicare UPIN