Provider Demographics
NPI:1891761433
Name:DAVIS, KATHRYN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 WASHINGTON AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7725
Mailing Address - Country:US
Mailing Address - Phone:616-393-0166
Mailing Address - Fax:
Practice Address - Street 1:926 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7725
Practice Address - Country:US
Practice Address - Phone:616-393-0166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076406174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301076406OtherPHYSICIAN LICENSE
MI4605877 TYPE 10Medicaid
MI5315015179OtherBOARD OF PHARMACY
BD8696669OtherDEA