Provider Demographics
NPI:1295783348
Name:DAVIS, DAVID A (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
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:PO BOX 10978
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0051
Mailing Address - Country:US
Mailing Address - Phone:479-283-3031
Mailing Address - Fax:888-229-0525
Practice Address - Street 1:609 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-757-4725
Practice Address - Fax:888-229-0525
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106442001Medicaid
AR51300Medicare PIN
AR106442001Medicaid