Provider Demographics
NPI:1356961296
Name:DAVIS, OLIVIA GWEN (DO)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GWEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3248 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-1320
Mailing Address - Country:US
Mailing Address - Phone:304-757-1031
Mailing Address - Fax:
Practice Address - Street 1:3248 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-1320
Practice Address - Country:US
Practice Address - Phone:304-757-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV4134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program