Provider Demographics
NPI:1841281326
Name:DAVIS, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
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 1:152 BUCKBOARD TRL
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:MT
Mailing Address - Zip Code:59741-8069
Mailing Address - Country:US
Mailing Address - Phone:847-345-5191
Mailing Address - Fax:
Practice Address - Street 1:152 BUCKBOARD TRL
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:MT
Practice Address - Zip Code:59741-8069
Practice Address - Country:US
Practice Address - Phone:847-345-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT91518207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060898Medicaid
IL036060898Medicaid
IL969190Medicare ID - Type UnspecifiedMEDICARE