Provider Demographics
NPI:1851339667
Name:DAVIS, GERALD FREDRIC (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:FREDRIC
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 1:90 S RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-2836
Mailing Address - Country:US
Mailing Address - Phone:914-937-0080
Mailing Address - Fax:914-937-0081
Practice Address - Street 1:90 S RIDGE ST
Practice Address - Street 2:
Practice Address - City:RYE BROOK
Practice Address - State:NY
Practice Address - Zip Code:10573-2867
Practice Address - Country:US
Practice Address - Phone:914-937-0080
Practice Address - Fax:914-937-0081
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109445174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2K5422Medicare ID - Type Unspecified
NYC12393Medicare UPIN
NY2K5421Medicare ID - Type Unspecified