Provider Demographics
NPI:1265793947
Name:DAVIS, LACY S (MD)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:S
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2017 W I 35 FRONTAGE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8504
Mailing Address - Country:US
Mailing Address - Phone:405-757-3365
Mailing Address - Fax:405-757-3366
Practice Address - Street 1:2017 W I 35 FRONTAGE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8504
Practice Address - Country:US
Practice Address - Phone:405-757-3365
Practice Address - Fax:405-757-3366
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK29259208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics