Provider Demographics
NPI:1245887728
Name:DAVIS, LARRY D JR (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:DEAN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:849 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2808
Mailing Address - Country:US
Mailing Address - Phone:608-755-7960
Mailing Address - Fax:608-755-7873
Practice Address - Street 1:849 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2808
Practice Address - Country:US
Practice Address - Phone:608-755-7960
Practice Address - Fax:608-755-7873
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8075-851390200000X
CAA185596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program