Provider Demographics
NPI:1205913506
Name:DAVIS, BRIAN WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WAYNE
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 1:4625 BORDEAUX BLVD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-8686
Mailing Address - Country:US
Mailing Address - Phone:859-533-3471
Mailing Address - Fax:
Practice Address - Street 1:4625 BORDEAUX BLVD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-8686
Practice Address - Country:US
Practice Address - Phone:859-533-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL29140207R00000X
NY256390207R00000X, 207RC0200X, 207RP1001X
MT18582207RC0200X, 207R00000X, 207RP1001X
NMMD2016-0024207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease