Provider Demographics
NPI:1831129493
Name:DAVENPORT, MARK WILBUR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILBUR
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 1:920 DELBON AVE
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2019
Mailing Address - Country:US
Mailing Address - Phone:209-634-7283
Mailing Address - Fax:209-634-9167
Practice Address - Street 1:920 DELBON AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2019
Practice Address - Country:US
Practice Address - Phone:209-634-7283
Practice Address - Fax:209-634-9167
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-31689207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G316892Medicaid
CAG-31689OtherCA LICENSE NUMBER
CAA91357Medicare UPIN
CA00G316892Medicaid