Provider Demographics
NPI:1780642900
Name:DAVIS, EDWIN B (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:B
Last Name:DAVIS
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 1:502 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-1533
Mailing Address - Country:US
Mailing Address - Phone:419-436-6697
Mailing Address - Fax:419-436-6612
Practice Address - Street 1:502 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-1533
Practice Address - Country:US
Practice Address - Phone:419-436-6697
Practice Address - Fax:419-436-6612
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35029216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0136392Medicaid
OHPENDINGOtherAETNA
OH000000375015OtherANTHEM
OHPENDINGOtherRRMC
OHPENDINGOtherTRICARE
OH04788OtherPARAMOUNT
OH24-54053OtherUHC
OH24-54053OtherUHC
OHPENDINGOtherAETNA