Provider Demographics
NPI:1891775920
Name:DAVIS, JOHN RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
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 1:4320 WORNALL RD
Mailing Address - Street 2:SUITE 50
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5941
Mailing Address - Country:US
Mailing Address - Phone:816-931-3312
Mailing Address - Fax:816-531-9862
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:SUITE 50
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-931-3312
Practice Address - Fax:816-531-9862
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010001724208G00000X
KS04-34175208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1815OtherMEDICARE
AR149549001Medicaid
MO209231208Medicaid
OK200009120AMedicaid
MOMA1815OtherMEDICARE
AR5M525Medicare ID - Type Unspecified