Provider Demographics
NPI:1851382634
Name:DAVIS, LAWRENCE GUSTAVO (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:GUSTAVO
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 1:6767 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5474
Mailing Address - Country:US
Mailing Address - Phone:706-522-4269
Mailing Address - Fax:970-652-2478
Practice Address - Street 1:6767 WEST 29TH STREET
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-652-2426
Practice Address - Fax:970-652-2478
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO47358208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025926100Medicaid
CO39126544Medicaid
WY133142600Medicaid
COP01022528OtherRR MEDICARE
CO39126544Medicaid
COA102983Medicare PIN