Provider Demographics
NPI:1023051315
Name:DAVIS, JAMES R (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:R
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 1:120 SPALDING DR
Mailing Address - Street 2:SUITE 307
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6508
Mailing Address - Country:US
Mailing Address - Phone:630-355-1102
Mailing Address - Fax:630-355-3078
Practice Address - Street 1:120 SPALDING DR
Practice Address - Street 2:SUITE 307
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6521
Practice Address - Country:US
Practice Address - Phone:630-355-1102
Practice Address - Fax:630-355-3078
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14162Medicare UPIN
IL637270Medicare ID - Type UnspecifiedPROVIDER NUMBER