Provider Demographics
NPI:1679532899
Name:DAVIS, IAN JONATHAN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:JONATHAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-2539
Mailing Address - Country:US
Mailing Address - Phone:919-966-5360
Mailing Address - Fax:919-966-8212
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-0001
Practice Address - Country:US
Practice Address - Phone:919-966-5360
Practice Address - Fax:919-966-8212
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1577922080P0207X
NC2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3185753Medicaid
53255OtherFALLON COMMUNITY HEALTH P
7863442OtherCIGNA
2928020OtherAETNA US HEALTHCARE
000000025972OtherBMC HEALTHNET
781010OtherTUFTS
204827OtherHPHC DFCI ONLY
MAJ19511OtherMASSACHUSETTS BLUE CROSS
MAJ19511OtherMASSACHUSETTS BLUE CROSS
MA3185753Medicaid