Provider Demographics
NPI:1669666764
Name:ALEX DAVENPORT MD PC
Entity Type:Organization
Organization Name:ALEX DAVENPORT MD PC
Other - Org Name:JAMES ALEXANDER DAVENPORT MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-656-1997
Mailing Address - Street 1:PO BOX 14266
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-4266
Mailing Address - Country:US
Mailing Address - Phone:850-656-1997
Mailing Address - Fax:850-656-1936
Practice Address - Street 1:2418 E PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5301
Practice Address - Country:US
Practice Address - Phone:850-656-1997
Practice Address - Fax:850-656-1936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALEX DAVENPORT MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-31
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25681207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059400800Medicaid
FL1601Medicare PIN
FL059400800Medicaid
FLF39858Medicare UPIN