Provider Demographics
NPI:1750087128
Name:DAVIS, CORY DUWAYNE SR
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:DUWAYNE
Last Name:DAVIS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 POST TOWN RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-3132
Mailing Address - Country:US
Mailing Address - Phone:937-559-4408
Mailing Address - Fax:
Practice Address - Street 1:6620 POST TOWN RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-3132
Practice Address - Country:US
Practice Address - Phone:937-559-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0481216Medicaid