Provider Demographics
NPI:1821179003
Name:DAVIS, JERRY THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:THOMAS
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 1:3963 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3202
Mailing Address - Country:US
Mailing Address - Phone:817-237-8273
Mailing Address - Fax:817-237-0374
Practice Address - Street 1:6302 A JACKSBORO HWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3602
Practice Address - Country:US
Practice Address - Phone:817-237-8273
Practice Address - Fax:817-237-0374
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75122Medicare UPIN
TX00RY85Medicare PIN