Provider Demographics
NPI:1710982517
Name:DAVENPORT, MICHAEL KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEITH
Last Name:DAVENPORT
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-344-1600
Mailing Address - Fax:859-344-0091
Practice Address - Street 1:20 MEDICAL VILLAGE DR STE 254
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-344-1600
Practice Address - Fax:859-344-0091
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32327208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2469136Medicaid
KY7100056850Medicaid
IN200078970Medicaid
KY64323272Medicaid
020035820OtherRAILROAD MEDICARE
IN201067710Medicaid
P00670401OtherRAILROAD MEDICARE
KY7100056850Medicaid
KY1459527Medicare PIN
IN201067710Medicaid
KYP00670401Medicare PIN
IN200078970Medicaid
KYK031560Medicare PIN
OH2469136Medicaid
KY3313263Medicare PIN
KY020035820Medicare PIN