Provider Demographics
NPI:1801975537
Name:DAVIS, ROBERT DANIEL (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DANIEL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5324
Mailing Address - Country:US
Mailing Address - Phone:203-334-6955
Mailing Address - Fax:203-334-2851
Practice Address - Street 1:2409 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5324
Practice Address - Country:US
Practice Address - Phone:203-334-6955
Practice Address - Fax:203-334-2851
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPOO312213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004070439Medicaid
533669OtherAETNA
Z5651OtherOXFORD
030000312CT02OtherANTHEM BLUE SHIELD
001932OtherHEALTH NET
1276009002OtherCIGNA
533669OtherAETNA
CT480000366Medicare PIN