Provider Demographics
NPI:1801850102
Name:DAVIS, STEPHEN OWEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:OWEN
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 1:6081 N 1ST ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5466
Mailing Address - Country:US
Mailing Address - Phone:559-431-5655
Mailing Address - Fax:
Practice Address - Street 1:6081 N 1ST ST
Practice Address - Street 2:#102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5466
Practice Address - Country:US
Practice Address - Phone:559-431-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30022207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG300220Medicare ID - Type Unspecified
CAOOG300221Medicare PIN