Provider Demographics
NPI:1134201213
Name:DAVIS, CRAIG T (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:T
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 1:405 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:618-529-0479
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1467
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0479
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107008207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910517Medicaid
P00354534OtherRAILROAD MEDICARE
IL036107008Medicaid
IL214881Medicare Oscar/Certification
NC2023050Medicare PIN
ILK32880Medicare PIN
P00354534OtherRAILROAD MEDICARE