Provider Demographics
NPI:1841303559
Name:DAVIS, KENLEY BRENT (MD)
Entity type:Individual
Prefix:
First Name:KENLEY
Middle Name:BRENT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17222 HOSPITAL BLVD STE 242
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-8925
Mailing Address - Country:US
Mailing Address - Phone:352-544-6145
Mailing Address - Fax:352-688-9189
Practice Address - Street 1:17222 HOSPITAL BLVD
Practice Address - Street 2:SUITE 326
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8925
Practice Address - Country:US
Practice Address - Phone:352-544-6145
Practice Address - Fax:352-688-9189
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94305208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30162YOtherMEDICARE ID
FL274800200Medicaid
FL30162OtherBCBS
C61710Medicare UPIN
FL30162ZMedicare PIN