Provider Demographics
NPI:1457360091
Name:DAVIS, LON MILES (MD)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:MILES
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 1:1600 S COULTER ST STE D-403
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1710
Mailing Address - Country:US
Mailing Address - Phone:806-358-0311
Mailing Address - Fax:806-358-6837
Practice Address - Street 1:1600 S COULTER ST STE D-403
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1710
Practice Address - Country:US
Practice Address - Phone:806-358-0311
Practice Address - Fax:806-358-6837
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3889174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00GA07Medicare ID - Type Unspecified
TXD48193Medicare UPIN