Provider Demographics
NPI:1851371918
Name:DAVIS, WILLARD III (DO)
Entity Type:Individual
Prefix:
First Name:WILLARD
Middle Name:
Last Name:DAVIS
Suffix:III
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 1:933 W VAN BUREN ST APT 716
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3595
Mailing Address - Country:US
Mailing Address - Phone:312-498-1195
Mailing Address - Fax:312-666-1640
Practice Address - Street 1:5645 W ADDISON ST
Practice Address - Street 2:OUR LADY OF THE RESURRECTION HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4403
Practice Address - Country:US
Practice Address - Phone:773-282-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112903207P00000X
TXM4024207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I47432Medicare UPIN