Provider Demographics
NPI:1780675975
Name:DAVIS, JIM D (DO)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 PALMER CIR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6301
Mailing Address - Country:US
Mailing Address - Phone:405-321-6405
Mailing Address - Fax:405-321-6457
Practice Address - Street 1:2400 PALMER CIR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6301
Practice Address - Country:US
Practice Address - Phone:405-321-6405
Practice Address - Fax:405-321-6457
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3845207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100850260CMedicaid
OK100850260AMedicaid
OK100850260CMedicaid
OK100850260AMedicaid