Provider Demographics
NPI:1780619635
Name:DAVENPORT, MICHAEL RAY (MD)
Entity type:Individual
Prefix:MISS
First Name:MICHAEL
Middle Name:RAY
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2320 E 93RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3983
Mailing Address - Country:US
Mailing Address - Phone:773-967-5002
Mailing Address - Fax:773-967-4191
Practice Address - Street 1:1049 E 46TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3618
Practice Address - Country:US
Practice Address - Phone:773-285-5902
Practice Address - Fax:773-285-1717
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42729Medicare UPIN