Provider Demographics
NPI:1760555916
Name:B J DAVIS DOPC
Entity Type:Organization
Organization Name:B J DAVIS DOPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:B
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-883-8099
Mailing Address - Street 1:3804 MONTGOMERY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQURQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109
Mailing Address - Country:US
Mailing Address - Phone:505-883-8099
Mailing Address - Fax:505-883-8060
Practice Address - Street 1:3804 MONTGOMERY NE
Practice Address - Street 2:
Practice Address - City:ALBUQURQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-883-8099
Practice Address - Fax:505-883-8060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:B J DAVIS DOPC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-16
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA40958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM41723Medicaid
NM41723Medicaid
NM101072Medicare PIN