Provider Demographics
NPI:1669523502
Name:DAVIS, JEFFERSON K (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:K
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:300 GALISTEO ST
Mailing Address - Street 2:STE 201
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2607
Mailing Address - Country:US
Mailing Address - Phone:505-983-6891
Mailing Address - Fax:505-982-2601
Practice Address - Street 1:300 GALISTEO ST
Practice Address - Street 2:STE 201
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2607
Practice Address - Country:US
Practice Address - Phone:505-983-6891
Practice Address - Fax:505-982-2601
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM90-1762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29931Medicaid
NM90176OtherMEDICAL LICENSE
NM29931Medicaid