Provider Demographics
NPI:1750464137
Name:DAVIS, JOHN WALTER (NIS-BC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WALTER
Last Name:DAVIS
Suffix:
Gender:M
Credentials:NIS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WINDSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2134
Mailing Address - Country:US
Mailing Address - Phone:860-644-3167
Mailing Address - Fax:
Practice Address - Street 1:1362 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1411
Practice Address - Country:US
Practice Address - Phone:860-658-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000340237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist