Provider Demographics
NPI:1831155308
Name:DAVILA, RENE (MD)
Entity type:Individual
Prefix:DR
First Name:RENE
Middle Name:
Last Name:DAVILA
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:P.O. BOX 24146
Mailing Address - Street 2:UNIVERSITY PHYSICIANS, PLLC
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4146
Mailing Address - Country:US
Mailing Address - Phone:601-984-4540
Mailing Address - Fax:601-984-4548
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPT OF MEDICINE DIVISION OF DIGESTIVE DISEASE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-984-4540
Practice Address - Fax:601-984-4548
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31854207R00000X, 207RG0100X, 207RI0008X
MS20542207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121826Medicaid
TN3845260Medicaid
MSP00755100Medicare PIN
3845260Medicare ID - Type Unspecified
TN3845260Medicaid
MS00121826Medicaid
G72602Medicare UPIN