Provider Demographics
NPI:1801906359
Name:DAVIS, DAVID J (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 BANNERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-0139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3560 E FLAMINGO RD
Practice Address - Street 2:STE. 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-0201
Practice Address - Country:US
Practice Address - Phone:702-433-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV137352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF68129Medicare UPIN