Provider Demographics
NPI:1700847191
Name:DAVIS, DEAN RYAN (MD)
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:RYAN
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 1:4155 MCCLAIN DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1238
Mailing Address - Country:US
Mailing Address - Phone:217-875-0227
Mailing Address - Fax:
Practice Address - Street 1:241 W WEAVER RD STE 145A
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9765
Practice Address - Country:US
Practice Address - Phone:217-876-5270
Practice Address - Fax:217-875-4001
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125071567207Q00000X
IL036150782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK35008Medicare PIN
9938610Medicare ID - Type Unspecified
ILK35009Medicare PIN
P39232Medicare UPIN