Provider Demographics
NPI:1255592903
Name:DAVIS, CORDELL ROSS (DO)
Entity type:Individual
Prefix:DR
First Name:CORDELL
Middle Name:ROSS
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4183
Mailing Address - Country:US
Mailing Address - Phone:701-780-4085
Mailing Address - Fax:701-780-4477
Practice Address - Street 1:4440 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7245
Practice Address - Country:US
Practice Address - Phone:701-732-7000
Practice Address - Fax:701-732-7696
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ND14283208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program