Provider Demographics
NPI:1710974191
Name:DAVENPORT, TERRY EVERT (DO)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:EVERT
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1813
Mailing Address - Country:US
Mailing Address - Phone:208-245-2591
Mailing Address - Fax:208-245-5246
Practice Address - Street 1:229 S 8TH ST
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1813
Practice Address - Country:US
Practice Address - Phone:208-245-2591
Practice Address - Fax:208-245-5246
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-130208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
601415700OtherDEEIOC
IDS1303OtherBLUE CROSS OF ID
WA123363OtherDEPT OF LABOR&INDUSTRIES
WA8434839Medicaid
ID805169900Medicaid
ID000010004699OtherREGENCE BS OF ID
G76557Medicare UPIN
WA8434839Medicaid
138503Medicare Oscar/Certification
0595810002Medicare NSC