Provider Demographics
NPI:1255158564
Name:DAVIS, JOHN TYLER
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NE 4TH ST APT 4310
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-2017
Mailing Address - Country:US
Mailing Address - Phone:816-500-4811
Mailing Address - Fax:
Practice Address - Street 1:13975 COLE CROSSING CT
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-9697
Practice Address - Country:US
Practice Address - Phone:816-500-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program