Provider Demographics
NPI:1669504122
Name:DAVIS, MARIANNE (DO)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2065
Mailing Address - Country:US
Mailing Address - Phone:607-754-9870
Mailing Address - Fax:607-785-9862
Practice Address - Street 1:401 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2065
Practice Address - Country:US
Practice Address - Phone:607-754-9870
Practice Address - Fax:607-785-9862
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY265514-1207V00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3487189Medicaid