Provider Demographics
NPI:1700871340
Name:DAVIS, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:815 CHILDS ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-4934
Mailing Address - Country:US
Mailing Address - Phone:662-286-3341
Mailing Address - Fax:662-286-9827
Practice Address - Street 1:815 CHILDS ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-4934
Practice Address - Country:US
Practice Address - Phone:662-286-3341
Practice Address - Fax:662-286-9827
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05258207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012610Medicaid
MS00012610Medicaid
B30461Medicare UPIN