Provider Demographics
NPI:1891938916
Name:DAVIS, RICHARD PERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PERRY
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:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-2400
Mailing Address - Country:US
Mailing Address - Phone:877-448-8675
Mailing Address - Fax:772-621-3184
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.054799207R00000X
FLME1202552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.1275555OtherSTATE OF ILLINOIS, DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
IL125.054799OtherTEMPORARY MEDICAL LICENSE