Provider Demographics
NPI:1952534539
Name:DAVIS, BRUCE BERNARD II
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:BERNARD
Last Name:DAVIS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 NW EXPRESSWAY
Mailing Address - Street 2:APT. 16131
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1700
Mailing Address - Country:US
Mailing Address - Phone:405-532-2741
Mailing Address - Fax:
Practice Address - Street 1:4101 NW EXPRESSWAY
Practice Address - Street 2:APT. 16131
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1700
Practice Address - Country:US
Practice Address - Phone:405-532-2741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS082321649Medicaid