Provider Demographics
NPI:1679583470
Name:DAVIS, BRIAN R (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9060
Mailing Address - Country:US
Mailing Address - Phone:801-952-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1325 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-9060
Practice Address - Country:US
Practice Address - Phone:801-253-3080
Practice Address - Fax:801-253-0772
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172302-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0565OtherMEDICAID LICENSE NUMBER
UTDH0042OtherRRMD GROUP
UT180043150OtherRAILROAD MEDICARE
UT1679583470Medicaid
UTDH0042OtherRRMD GROUP
UT000066116Medicare PIN
UT180043150OtherRAILROAD MEDICARE