Provider Demographics
NPI:1790709210
Name:DAVENPORT, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
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 60063
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0063
Mailing Address - Country:US
Mailing Address - Phone:704-302-8500
Mailing Address - Fax:704-302-8501
Practice Address - Street 1:332 SAM NEWELL RD
Practice Address - Street 2:SUITE 2000
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-6566
Practice Address - Country:US
Practice Address - Phone:704-302-8500
Practice Address - Fax:704-302-8501
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24374207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927174Medicaid
NC8927174Medicaid
C83456Medicare UPIN