Provider Demographics
NPI:1679123475
Name:DAVIS, MARK ISAAC
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ISAAC
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ROSALIND REDFERN GROVER PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-5856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY STE 240
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5856
Practice Address - Country:US
Practice Address - Phone:432-221-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2571207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty