Provider Demographics
NPI:1962446898
Name:DAVIS, ANTHONY DEWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:DEWAYNE
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 1:1379 BRAD CIRCLE STE A
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771
Mailing Address - Country:US
Mailing Address - Phone:903-881-5165
Mailing Address - Fax:903-881-5175
Practice Address - Street 1:1379 BRAD CIRCLE STE A
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771
Practice Address - Country:US
Practice Address - Phone:903-881-5165
Practice Address - Fax:903-881-5175
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116319807Medicaid
P00017436OtherMEDICARE RR
G99379Medicare UPIN
P00017436OtherMEDICARE RR
P00017436Medicare PIN