Provider Demographics
NPI:1811999063
Name:DAVENPORT, RICHARD D (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2424 S 90TH ST
Mailing Address - Street 2:STE 506
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2455
Mailing Address - Country:US
Mailing Address - Phone:414-328-8760
Mailing Address - Fax:414-328-8763
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:STE 506
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8760
Practice Address - Fax:414-328-8763
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2015-12-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI19876207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI18197019OtherPALMETTO GBA-RAILROAD
WI30939300Medicaid
WI30939300Medicaid
WIB52319Medicare UPIN
WI18197019OtherPALMETTO GBA-RAILROAD