Provider Demographics
NPI:1669865861
Name:DAVIS, GINA DOLORESCO (DO)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:DOLORESCO
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:DOLORESCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:621 S NEW BALLAS RD STE 560A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8261
Mailing Address - Country:US
Mailing Address - Phone:314-251-6440
Mailing Address - Fax:314-251-4456
Practice Address - Street 1:621 S NEW BALLAS RD STE 560A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8261
Practice Address - Country:US
Practice Address - Phone:314-251-6440
Practice Address - Fax:314-251-4456
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2020011640390200000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program