Provider Demographics
NPI:1952303315
Name:DAVENPORT, MARK ROGERS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROGERS
Last Name:DAVENPORT
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 1718
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37816-1718
Mailing Address - Country:US
Mailing Address - Phone:423-581-5987
Mailing Address - Fax:423-581-0984
Practice Address - Street 1:1027 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-6632
Practice Address - Country:US
Practice Address - Phone:423-581-5984
Practice Address - Fax:423-581-0984
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026233207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3089699Medicaid
TN3089699Medicaid