Provider Demographics
NPI:1912128356
Name:DAVIS, GLEN PRIESTER (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:PRIESTER
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 1:198 E 121ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-3523
Mailing Address - Country:US
Mailing Address - Phone:212-803-2727
Mailing Address - Fax:646-335-0667
Practice Address - Street 1:198 E 121ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3523
Practice Address - Country:US
Practice Address - Phone:212-803-2727
Practice Address - Fax:646-335-0667
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2390492084P0800X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No282N00000XHospitalsGeneral Acute Care Hospital