Provider Demographics
NPI:1760653505
Name:DAVENPORT, TIMOTHY C (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
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 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-425-5752
Mailing Address - Fax:731-425-5783
Practice Address - Street 1:145 INNOVATION DR
Practice Address - Street 2:STE 300
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3019
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-422-0402
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45054208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4231017OtherBCBS NUMBER
TN1514816Medicaid
TN4231017OtherBCBS NUMBER
TNP00735241Medicare PIN