Provider Demographics
NPI:1811409576
Name:DAVIS, ROGER WAYNE
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 MORRIS LN
Mailing Address - Street 2:
Mailing Address - City:MONTROSS
Mailing Address - State:VA
Mailing Address - Zip Code:22520-2952
Mailing Address - Country:US
Mailing Address - Phone:804-493-3214
Mailing Address - Fax:804-493-3215
Practice Address - Street 1:539 MORRIS LN
Practice Address - Street 2:
Practice Address - City:MONTROSS
Practice Address - State:VA
Practice Address - Zip Code:22520-2952
Practice Address - Country:US
Practice Address - Phone:804-493-3214
Practice Address - Fax:804-493-3215
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD$$$$$$$$$OtherDON’T HAVE ONE
VA$$$$$$$$$OtherDON’T HAVE ONE