Provider Demographics
NPI:1689788630
Name:DAVIS, DENNON W (MD)
Entity Type:Individual
Prefix:
First Name:DENNON
Middle Name:W
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:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:502 W SAINT LOUIS ST STE 4
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-1968
Practice Address - Country:US
Practice Address - Phone:618-937-3400
Practice Address - Fax:618-997-9324
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10019630OtherBCBS
334689OtherHEALTH LINK
047016OtherHEALTH ALLIANCE
080137051OtherRAILROAD MEDICARE
10019630OtherBCBS
334689OtherHEALTH LINK
IL214881Medicare Oscar/Certification