Provider Demographics
NPI:1720074081
Name:DAVIS, JAMES R (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 HIDDEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-9684
Mailing Address - Country:US
Mailing Address - Phone:405-376-5121
Mailing Address - Fax:
Practice Address - Street 1:5525 HIDDEN MEADOW DR
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-9684
Practice Address - Country:US
Practice Address - Phone:405-376-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3657207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100103050CMedicaid