Provider Demographics
NPI:1679590129
Name:DAVIS, DAVID S (MD, JD, FACEP)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD, JD, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13205 BOOKER T WASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:VA
Mailing Address - Zip Code:24101-3947
Mailing Address - Country:US
Mailing Address - Phone:540-719-1815
Mailing Address - Fax:540-719-2867
Practice Address - Street 1:13205 BOOKER T WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-3947
Practice Address - Country:US
Practice Address - Phone:540-719-1815
Practice Address - Fax:540-719-2867
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101026320207P00000X, 207P00000X
MDD22017207P00000X
MO2004029820207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2004029820Medicaid
IL036104209Medicaid
MO208731919Medicaid
ILK17131Medicare PIN
MOMA1371002Medicare PIN
MO2004029820Medicaid
IL036104209Medicaid