Provider Demographics
NPI:1295760080
Name:DAVIS, BRYAN W (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 CREEKBEND BLVD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1781
Mailing Address - Country:US
Mailing Address - Phone:936-205-5949
Mailing Address - Fax:936-205-5953
Practice Address - Street 1:129 CREEKBEND BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1781
Practice Address - Country:US
Practice Address - Phone:936-205-5949
Practice Address - Fax:936-205-5953
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154032004Medicaid
TXH32947Medicare UPIN
TX154032004Medicaid