Provider Demographics
NPI:1720165772
Name:DAVIS, MARK EMBREY (DO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EMBREY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2223 LIME KILN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6213
Mailing Address - Country:US
Mailing Address - Phone:920-430-8120
Mailing Address - Fax:920-430-8122
Practice Address - Street 1:2223 LIME KILN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6213
Practice Address - Country:US
Practice Address - Phone:920-430-8120
Practice Address - Fax:920-430-8122
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-09-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI34460207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30059100Medicaid
WI30059100Medicaid
WI000407027Medicare PIN
E76745Medicare UPIN