Provider Demographics
NPI:1265403182
Name:DAVIS, SUSAN REBECCA (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:REBECCA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 89TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-2904
Mailing Address - Country:US
Mailing Address - Phone:806-798-7676
Mailing Address - Fax:
Practice Address - Street 1:4301 89TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-2904
Practice Address - Country:US
Practice Address - Phone:806-798-7676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8070207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139779621Medicaid
TXC15083Medicare UPIN
TX8525B9Medicare ID - Type Unspecified