Provider Demographics
NPI:1851373674
Name:DAVENPORT, CHARLES W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:DAVENPORT
Suffix:JR
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 1:1800 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4158
Mailing Address - Country:US
Mailing Address - Phone:601-703-9506
Mailing Address - Fax:601-703-3264
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-703-4065
Practice Address - Fax:601-703-3050
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13521207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060048292OtherTRICARE
731-02314OtherBLUE CROSS OF AL
MS00115846Medicaid
AL009809870Medicaid
731-02314OtherBLUE CROSS OF AL
MS00115846Medicaid