Provider Demographics
NPI:1750410759
Name:IRA DAVIS, MD, PLLC
Entity type:Organization
Organization Name:IRA DAVIS, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-774-2478
Mailing Address - Street 1:280 N CENTRAL AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-1832
Mailing Address - Country:US
Mailing Address - Phone:914-288-0500
Mailing Address - Fax:914-288-0260
Practice Address - Street 1:2627 HYLAN BLVD # C
Practice Address - Street 2:BOX 10
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-477-4022
Practice Address - Fax:718-698-9573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182268207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP2869871OtherOXFORD ID#
NY3K2111OtherBC
NYP00221021OtherRR MCR
NYOH4223OtherHEALTHNET
NYOH4223OtherHEALTHNET
NYE86323Medicare UPIN
NY82F472Medicare PIN