Provider Demographics
NPI:1871507251
Name:DAVIS, JEFFREY RICH (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICH
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 1:1801 1ST AVE
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-636-4469
Mailing Address - Fax:360-425-4970
Practice Address - Street 1:1801 1ST AVE
Practice Address - Street 2:SUITE 3A
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-636-4469
Practice Address - Fax:360-425-4970
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038750207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8256067Medicaid
WAAB24023Medicare PIN
WA8863943Medicare PIN