Provider Demographics
NPI:1952391401
Name:DAVENPORT, WILLIAM WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WAYNE
Last Name:DAVENPORT
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 1:582 ISLAND WALK E
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7834
Mailing Address - Country:US
Mailing Address - Phone:501-815-4924
Mailing Address - Fax:
Practice Address - Street 1:582 ISLAND WALK E
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7834
Practice Address - Country:US
Practice Address - Phone:501-815-4924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-43652085N0700X, 2085R0202X
ARE4365174400000X
GA763252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157517001Medicaid
ARE4365OtherSTATE LICENSE
BD6452899OtherDEA LICENSE
BD6452899OtherDEA LICENSE
ARH78819Medicare UPIN
ARE4365OtherSTATE LICENSE
56799Medicare UPIN